Spontaneous gangrene and perforation of choledochal cyst: a rare presentation
DOI:
https://doi.org/10.18203/2349-2902.isj20151110Keywords:
Choledochal cyst, Perforation, T-tube cholangiogram, GangreneAbstract
Choledochal cyst is a rare entity. It generally presents in children with pain, jaundice and the occasional finding of a lump in right hypochondriac region. A very rare presentation is biliary peritonitis resulting from a perforated choledochal cyst. It is usually seen in younger children. Our patient was a 14 year old female who presented with an acute abdomen. Clinically she had signs of peritonitis. Chest radiograph did not show free gas under diaphragm. The USG showed a dilated CBD of 4.1cm with a calculus at its lower end of 2 x 2.6cm, USG guided diagnostic tap revealed bile. Emergency exploration was done, a gangrenous patch of size 3 * 2cm in the anteromedial wall of large choledochal cyst was found with a perforation in it. No calculous was found. The gangrenous wall of choledochal cyst was excised and primary suturing of choledochal cyst was done with a T-tube placed through separate incision in choledochal cyst. As there is no facility for intra-operative cholangiogram in the emergency setting in our institute, a post-operative cholangiogram was done on day 7. It revealed a dilated CBD, CHD as well as right and left hepatic ducts (choledochal cyst type IA). The patient was discharged and asked to follow-up electively for excision of choledochal cyst at a later date. A rare possibility of a perforated choledochal cyst should be kept in mind in cases of biliary peritonitis, especially in younger age groups. Bile drainage would be a safer procedure in emergency condition, especially when patient presented late to hospital with hemodynamic unstability and edematous wall.
References
Ueno S, Hirakawa H, Yokoyama S, Imaizumi T, Makuuchi H. Emergent biliary drainage for choledochal cyst. Tokai J Exp Clin Med. 2005;30:1-6.
She WH, Chung HY, Lan LC, Wong KK, Saing H, Tam PK. Management of choledochal cyst: 30 years of experience and results in a single center. J Pediatr Surg. 2009;44:2307-11.
Fragulidis GP, Marinis AD, Anastasopoulos GV, Vasilikostas GK, Koutoulidis V. Management of a ruptured bile duct cyst. J Hepatobiliary Pancreat Surg. 2007;14:194-6.
Waidner U, Henne-Bruns D, Buttenschoen K. Choledochal cyst as a diagnostic pitfall: A case report. J Med Case Reports. 2008;2:5.
Treem WR, Hyams JS, McGowan GS, Sziklas J. Spontaneous rupture of a choledochal cyst: Clues to diagnosis and etiology. J Pediatr Gastroenterol Nutr. 1991;13:301-6.
Karnak I, Tanyel FC, Büyükpamukçu N, Hiçsönmez A. Spontaneous rupture of choledochal cyst: An unusual cause of acute abdomen in children. J Pediatr Surg. 1997;32:736-8.
Chijiiwa K , Koga A. Surgical management and long term follow up of patients with choledochal cysts. Am J surg. 1993;165:238-42
Yamaguchi M. congenital choledochal cyst. Analysis of 1,433 patients in the Japenese literature. Am J Surg. 1980;140:653
Treem WR, Hyams JS, McGowan GS, Sziklas J. Spontaneous Rupture of a Choledochal Cyst: Clues to Diagnosis and Etiology. J Pediatr Gastroenterol Nutr. 1991;13:301-6.
Chen WJ, Chang CH, Hung WT. Congenital choledochal cyst: With observations on rupture of the cyst and intrahepatic ductal dilatation. J Pediatr Surg. 1973;8:529-38
Friend WD. Rupture of choledochal cyst during confinement. Br J Surg. 1958;46:155-7.