Choledochal cyst
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- A 13-year-old female presented with epigastric pain and vomiting for the past 2 years. Imaging showed a cystic area in the common bile duct. MRCP revealed a well-defined cystic lesion with calculi, suggestive of a choledochal cyst type 2. - The patient underwent excision of the choledochal cyst with Roux-en-Y loop formation. Post-op recovery was uneventful. - Choledochal cysts are rare congenital dilations of the biliary tree that are more common in females. Complete surgical excision is the recommended treatment to prevent complications like cholangiocarcinoma.
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(1) 78 year old white female presents with increasing abdominal distention, vomiting, cramping abdominal pain, and 3 days of constipation. She has a history of chronic constipation.
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Choledochal cysts - Introduction, Classification, Pathogenesis & Management
Choledochal cysts - Introduction, Classification, Pathogenesis & ManagementNepal Medical College and Teaching Hospital
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)Choledochal cyst
This Presentation gives general overview of how patient with Choledochal Cyst presents and what workup should be done and how such patients should be managed
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- Presentation of bile duct injuries, which can be either immediately post-op or months/years later, depending on the type and severity of injury.
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- Surgical repair approaches like end-to-end anastomosis or biliary enteric procedures depending on the type and location of injury.
- Managing injuries presenting later as biliary strictures or leaks, often through staged approaches using external drainage first.
- Techniques for different stricture types, including exposing healthy ducts proximally and creating mucosa-to-mucosa anastomoses to distal conduits.
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(1) 78 year old white female presents with increasing abdominal distention, vomiting, cramping abdominal pain, and 3 days of constipation. She has a history of chronic constipation.
(2) X-ray findings include dilated colon over 6cm, effacement of haustrae peripherally located, and multiple air fluid levels consistent with large bowel obstruction.
(3) Treatment includes IV fluids, analgesics, NG tube, antibiotics, and surgery consult with emergency laparotomy if signs of peritonitis, free air, or sepsis are present.
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2. Chronic pancreatitis is characterized by persistent inflammation and irreversible fibrosis of the pancreas that decreases quality of life and can cause pain and exocrine/endocrine insufficiency.
3. Heavy alcohol consumption is the most common cause, accounting for 70-80% of cases, while other risks include genetic mutations, duct obstructions, trauma, and tropical or autoimmune etiologies.
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This document defines different types of gastrointestinal bleeding and their associated symptoms. Upper GI bleeding originates from the esophagus, stomach or duodenum and can cause haematemesis (vomiting of blood) or coffee ground vomitus. Lower GI bleeding originates from the small bowel or colon and can cause melena (black tarry stools) or hematochezia (fresh blood in stool). The document notes that bright red haematemesis implies active upper GI bleeding, which is a major medical emergency. It also lists causes of upper GI bleeding and references management guidelines, with plans to cover differential diagnosis of GI bleeding in more detail later.
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Surgical management of ulcerative colitis includes both emergency and elective procedures. Emergency surgeries are indicated for complications like toxic megacolon or hemorrhage. Elective surgeries are considered for intractable disease or risk factors like dysplasia. Common procedures include subtotal colectomy, proctocolectomy with Brooke ileostomy, and restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The IPAA aims to restore continence but has risks of complications like pouchitis or rarely Crohn's disease developing in the pouch. Long term surveillance after surgery is important to monitor for issues.
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3. Treatment requires urgent surgery to address the cause, such as reducing a hernia or untwisting a volvulus. Resection may be needed for non-viable bowel segments. Post-operative care focuses on monitoring for complications like infection or anastomotic leakage.
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Choledochal cysts - Introduction, Classification, Pathogenesis & Management
Choledochal cysts - Introduction, Classification, Pathogenesis & ManagementNepal Medical College and Teaching Hospital
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)Choledochal cyst
This Presentation gives general overview of how patient with Choledochal Cyst presents and what workup should be done and how such patients should be managed
Choledochal cyst
1. Choledochal cysts are abnormal dilations of the bile ducts that are more common in Asia and women.
2. They are classified into 5 types based on location and extent of dilation.
3. Presentation varies from jaundice and abdominal mass in children to pain and cholangitis in older patients.
4. Investigation involves ultrasound, CT, MRCP and cholangiography to determine type and rule out complications.
5. Treatment is complete excision of the cysts and biliary tree with Roux-en-Y hepaticojejunostomy, except for type III which can be managed endoscopically.
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A 6-year-old female presented with right flank pain. Imaging showed dilatation of the common bile duct consistent with a choledochal cyst. She underwent surgery where a choledochal cystectomy and Roux-en-Y hepaticojejunostomy was performed. Pathology confirmed a type 1a choledochal cyst. Post-operatively, her recovery was uneventful.
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A 2-year old female child was found to have a dilated common bile duct (choledochal cyst) on sonography. The document describes the etiology, pathogenesis, classification and imaging findings of choledochal cysts. Specifically, it states that choledochal cysts are most commonly due to anomalous pancreaticobiliary drainage, which allows pancreatic secretions to reflux into the bile duct and cause dilatation. It also describes the Todani classification system for choledochal cysts, noting this case is a Type 4A cyst, which involves dilatation of both intrahepatic and extrahepatic bile ducts.
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Choledochal cyst
- 1. Case discussion Dr Muhammad Ihtesham PGT SU2 BBH RWP.
- 2. Brief history Patient rubab, 13 year old female, presented through opd with C/O Pain epigastrium for 2 years vomiting on and off for 2 years
- 3. History of presenting complaints Epigastric pain was gradual in onset, severe in intensity and radiating to back. Pain was related to intake of fatty and spicy diet and relieved by taking medicine. Vomiting was non projectile and related to pain and yellowish green in colour containing food particles.
- 4. • There was no history of weight loss, dysphagia, anorexia, bleeding PR, hematemesis, yellowish discoloration of sclera, clay colored stool or dark colored urine. • No history of flatulence or heart burn.
- 5. Systemic inquiry • Respiratory system: not significant • Cardiovascular system: not significant • Gastrointestinal system: pain epigastrium, vomiting, nausea, on and off constipation, indigestion • Nervous system: not significant • Musculoskeletal system: not significant
- 6. Previous history • There is no significant previous history, drug history of family history. • Previous medical and surgical history is also insignificant
- 7. General physical examination • BP= 110/70 • Pulse= 80/min • Temperature= A/F • R/R= 16/min • There was no clinical jaundice, cervical or axillary lymph adenopathy, anemia or dilated veins in neck. Rest of the the GPE is normal.
- 8. Systemic examination GIT Inspection: Non distended abdomen, central umbilicus, normal hair distribution. No visible dilated veins or pulsations Palpation: Abdomen soft non-tender, no visceromegaly or mass palpable Percussion: resonant note, no ascites detected Auscultation: Bowel sounds were audible • Respiratory system: normal vesicular breathing • CNS: conscious and oriented • CVS: S1+S2+0
- 9. Differential diagnosis • Acid peptic disease • Gastritis • Esophagitis • Acute cholecystitis • Acute pancreatitis • Choledochal cyst • Pancreatic divisum
- 10. Investigations • Blood cp: Hb=12g/dl TLC=7*103 • LFT’s TBIL=0.8 ALT=22 ALP=74 • RFT’s= WNL • PT/APTT= WNL
- 11. USG abdomen • It showed cystic area of 4.8 * 3.1cm seen in proximal part of CBD/CHD. • Rest of the USG was normal
- 12. MRCP • Well defined cystic lesion with calculi, lying adjacent to common bile duct. Features suggestive of choledochal cyst type 2. • Contracted GB with cholelithiasis.
- 14. Diagnosis Type 1 diffuse choledochal cyst
- 15. Management Excision of the choledochal cyst with Roux en y loop formation
- 16. Per op findings • Fusiform choledochal cyst starting from about 1.5cm proximal to insertion into duodenum and extending all the way up to CHD. • Cystic duct opening into the cyst. All the planes surrounding the cyst were well preserved. • Abdominal drain placed in subhepatic space.
- 19. Post op status of the patient • Patient is maintaining the vitals throughout the post op period. • Urine output is adequate. • Drain output: day 1= 200ml/ 24hrs day 2=350ml/24hrs day 5= 1000ml/ 24hrs day 6=
- 20. Post op investigations • Hb= 8.9g/dl • Hct = 27 • Plt= 189* 103 • TBIL= 0.8 • ALP= 78 • Urea = 18 • Creat= 0.3 • Na+ = 136 • K+ = 3.8 • Cl- = 97 • S. amylase= 3267 and 499 • S.lipase= 318
- 21. Active complaints • 2 spikes of high grade fever • Nausea • Productive cough
- 22. Discussion • Can ERCP and PTC be useful techniques for the hepatobiliary imaging ?
- 23. Literature review Choledochal cysts are congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary tree. They are rare—the incidence is between 1:100,000 and 1:150,000 in populations of Western countries. Choledochal cysts affect females three to eight times more often than males. Although frequently diagnosed in infancy or childhood, as many as one half of the patients have reached adulthood when diagnosed.
- 24. Cause weakness of the bile duct wall and increased pressure secondary to partial biliary obstruction are required for biliary cyst formation. Adults commonly present with jaundice, cholangitis or pancreatitis. Less than one half of patients present with the classic clinical triad of abdominal pain, jaundice, and a mass.
- 25. Types of choledochal cysts
- 26. Caroli’s disease • Type VI( both intra and extrahepatic) choledochal cyst which is a hereditary disorder, is known as Caroli disease and carries a poor prognosis from recurrent cholangitis and the development of intrahepatic stones, liver abscess formation and, eventually, cirrhosis.
- 27. Grumbach disease • In some patients, multiple intrahepatic cystic disease is accompanied by congenital hepatic fibrosis. This condition is known as Grumbach disease.
- 28. How to investigate Ultrasonography or CT scanning will confirm the diagnosis, but endoscopic cholangiography, transhepatic cholangiography, or MRCP is required to assess the biliary anatomy and to plan the appropriate surgical treatment.
- 29. Treatment For types I, II, and IV, excision of the extrahepatic biliary tree, including cholecystectomy, with a Roux-en-Y hepaticojejunostomy is ideal. In type IV, additional segmental resection of the liver may be appropriate, particularly if intrahepatic stones, strictures, or abscesses are present or if the dilatations are confined to one lobe.
- 30. • The risk of cholangiocarcinoma developing in choledochal cysts is as high as 15% in adults and supports complete excision when they are diagnosed. For type III, sphincterotomy is recommended.
- 31. Thank you