A. A. Ali et al. / Open Journal of Gastroenterology 3 (2013) 84-86
Copyright © 2013 SciRes.
86
Sarris and Tsang proposed in 1988 a more precised
classification [3]:
OPEN ACCESS
Type A = it corresponds to the ampullar form; the
most frequent wit h 67 %. It is divi ded into 3 subty pes,
A1 = the choled oque and the wirsung duct meet into a
commun duct that opens into the choledocal cyst;
A2 = the bilio pancreatic anastomoses are distant;
A3 = intramural and small choledochal cyst.
Type B = 21% are close to the diverticular form.
In our case, the adequate analysis of the cholan-
giograpic images showed that both, Wirsung and com-
mon ducts are distant and open separatly into the chole-
dochal cyst which corr esp onds to the ampu llar typ e A2 , a
very rare f orm.
Clinical signs of choledochal cyst are chronic and non
specific dominated by biliary pain (91%); jaundice and
recurrent attacks of acute pancreatitis (30% - 38%). The
association with biliary duct stones is noted in 17% to
21% of cases [1]. The upper obstructive signs of the di-
gestive system were also reported. The risk of degenera-
tion estimated initially to 15% have now decreased to
only 2.5% Intraoperative cholangiography and ERCP are
the main diagnostic examinations of the cyst [3]. They
enable us to define its volume, the state of the biliary
ducts, the presence of stones and the mode of anastomo-
sis of the different biliopancreatic d ucts.
Lateral vision duodenoscopy may show a protruding
formation of the papillary region. Papillary orifice is not
always visible and its catheterisation is quite difficult.
Echo endoscopy may facilitate the finding of a cystic
dilatation and hence eleminating the presence of a solid
tumor beneath the duodenal mucosa, but it does not give
us a good analysis of biliopancreatic ducts. MRI of the
biliary system gives us a precise study of the extrahepatic
ducts with a main performance approaching 90% [5];
however a solid tumor cannot be certainly eleminated.
The clinical signs of our patient were not specific in
the way that she had jaundice, weight loss associated
with the suspicion of a malignant stenosis of principal
biliary duct in the imaging tests. This weight loss is ex-
plained by the ulcerated bulbar stenosis. The choledochal
cyst was discovered intraoperatively, the tumoral-like
stenosis of the common bile duct seen during MRI cor-
responds to the anastomosis of this latter with the cyst. It
is the accurate study of the cholangiographic images, the
macroscopic aspect and examination of the papillary
region after duodenotomy that prevented us from doing a
cephalic duodenopancreatectomy.
However we cannot establish a precise diagnosis even
intraoperatively because we may miss a small neoplastic
lesion in the papilla and the role of echo-endoscopy is
important.
The classical treatment was the resection of the cyst
either partially or totally with reimplantatio n of the bilio-
pancreatic ducts, since it was initially considered as a
high risk of degeneration [1]. Actually, this strategy is
progressively replaced by endoscopic management, and
it became the first choice in the treatment of choledocal
cyst, especially in type A3 or A1 and A2 with a small
size [3,4].
However partial resection of the cyst with the presser-
vation of biliopancreatic ducts is preferred, mainly in
case of a large cyst or a doubtful diagnosis, as in our
clinical case [3].
4. CONCLUSION
The diagnosis of choledochal cyst is very difficult. It has
many similarities with common bile duct cholangiocari-
noma. In our case, the chief complaint of the patient is
recurrent jaundice associated with abdominal pain. The
liver function test shows cholestasis and the MRI shows
a dilatation of intrah epatic, pancreatic ducts and common
bile duct, and there is a stenosis in the lower part of the
common bile duct. The first diagnosis of common bile
duct cholangiocarinoma is under suspicion. The intraop-
erative cholangiography shows a separate protrusion at
the papillary region, and the partial resection of the pa-
pilla shows no any tumoral lesion.
REFERENCES
[1] Berger, A., Douard, R., Landi, B., Poupardin, E., Canard,
J.M., Cellier, C., et al. (2007) Endoscopic management of
a large choledochocele associated with choledocholithi-
asis. Gastroentérologie Clinique et Biologique, 31, 200-
203. doi:10.1016/S0399-8320(07)89356-0
[2] Mannai, S., Kraiem, T., Gharbi, L., Haoues, N., Mestiri,
H. and Khalfallah, M.T. (2006) Les dilatations kystiques
congénitales des voies biliaires. Annales de Chirurgie,
131, 369-374. doi:10.1016/j.anchir.2006.03.008
[3] Fritsch, J., Prat, F., Pelletier, G. and Buffet, C. (1999)
Anomalies anatomiques de la région papillaire et pathol-
ogie bilio-pancré atique. Gastroentéro logie Clinique et Biol-
ogique, 23, 717-729.
[4] Ladas, S.D., Katsogridakis, I., Tassios, P., Tastemiroglou,
T., Vrachliotis, T. and Raptis, S.A. (1995) Choledocho-
cele, an overlooked diagnosis: Report of 15 cases and re-
view of 56 reports from 1984 to 1992. Endoscopy, 27,
233-239. doi:10.1055/s-2007-1005677
[5] Kabbaj, N., Ababou, A., El Fakir, Y., Amarouch, N.,
Dafiri, R., Sbihi, A., et al. (1998) A propos d’un cas de
pancréatite aigue révélant une dilatation kystique du cho-
lédoque. Journal of Radiology, 79, 1393-1397.