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Journal of Indian Association of Pediatric Surgeons
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CASE REPORT
Year : 2007  |  Volume : 12  |  Issue : 2  |  Page : 83-84
 

Hydatid cyst of common bile duct mimicking type 1 choledochal cyst


1 Department of Surgery, Burdwan Medical College, Burdwan, West Bengal - 713 101, India
2 Department of Anaesthesia, Burdwan Medical College, Burdwan, West Bengal - 713 101, India

Correspondence Address:
Utpal De
K-1/3, Phase-2A, Dankuni Housing Complex, Dankuni, Hooghly, West Bengal - 711 224
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.33229

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   Abstract 

A 11 year-old girl presented with pain in the abdomen, an abdominal mass and jaundice. Clinical examination and investigations suggested a diagnosis of a type 1 choledochal cyst. Upon operation, a solitary, unruptured hydatid cyst was found obstructing the common bile duct. Intrinsic obstruction of the extrahepatic bile duct by a solitary hyatic cyst without any hepatic involvement as seen in this unique case, has not been reported until now.


Keywords: Common bile duct, hydatid cyst, jaundice


How to cite this article:
De U, Basu M. Hydatid cyst of common bile duct mimicking type 1 choledochal cyst. J Indian Assoc Pediatr Surg 2007;12:83-4

How to cite this URL:
De U, Basu M. Hydatid cyst of common bile duct mimicking type 1 choledochal cyst. J Indian Assoc Pediatr Surg [serial online] 2007 [cited 2019 Sep 15];12:83-4. Available from: http://www.jiaps.com/text.asp?2007/12/2/83/33229



   Introduction Top


Parasitic causes of biliary duct obstruction include Fasciola hepatica , Ascariasis and hydatid cysts. [1] Bile duct obstruction associated with hydatid disease may occur in three ways: 1) obstruction of bile ducts by intrahepatic cysts, 2) rupture of cysts into the bile ducts and subsequent intrinsic obstruction caused by the hydatid material and 3) extrinsic compression of bile ducts by a hydatid cyst with or without accompanying liver cysts. [2] We report a rare case of an unruptured solitary hydatid cyst inside the common bile duct (CBD) without any hepatic involvement, presenting with obstructive jaundice mimicking a type 1 choledochal cyst.


   Case Report Top


An 11 year-old girl was admitted to the hospital with jaundice, clay-colored stool, itching and dark urine, these symptoms existing since the past five months. There was no previous history of biliary disease or jaundice. On physical examination, she was icteric and the liver was palpable just below the right costal margin. A semi-mobile mass 8 cm x 6 cm was palpated in the right upper quadrant.

Laboratory investigations revealed levels of hemoglobin = 10.6 g/dL, white blood cell count = 7200/ mm 3 without eosinophilia; bilirubin = 6.4 g/dL (conjugated: 3.5 and unconjugated: 2.9), alkaline phosphatase = 362 IU/L, aspartate aminotransferase = 111 IU/L, alanine aminotransferase = 115 IU/L, gamma glutamyltranspeptidase = 64 IU/L, blood sugar (postprandial, PP) = 93 mg/dL, urea = 30 mg/dL, creatinine = 0.8 mg/dL, HbsAg-negative, prothrombin time = 16 seconds (control = 14 seconds).

Abdominal ultrasonography (USG) findings were consistent with the diagnosis of type I choledochal cyst with a distended, edematous gall bladder without stones, mild hepatomegaly and dilated intrahepatic bile ducts (intrahepatic biliary radicals, IHBR). The common bile duct was fusiform-shaped and measured 105 mm x 98 mm x 87 mm and showed evidence of a multilayered, linear, echogenic area within it. Computed tomography (CT) showed similar findings [Figure - 1]. Thus, USG and CT findings were interpreted as the presence of a type 1 choledochal cyst.

Upon operation, the gall bladder was found to be edematous and distended. The CBD was replaced by a fusiform swelling measuring 9 cm x 8 cm x 8 cm. Palpation of the gall bladder revealed no stones. Cholecytectomy was performed and progressive dissection of the CBD for Roux-en-Y hepaticojejunostomy was undertaken. The tapered lower end of the retroduodenal CBD was dissected, transected and ligated.

The proximal part of the CBD was dissected up to about a cm below the hilum. On transection of the proximal part of the dilated duct, an unruptured solitary cyst was discovered [Figure - 2] and a diagnosis of a hydatid cyst was made. A Roux-en-Y hepaticojejunostomy was performed. The abdomen was inspected thoroughly but no evidence of any hydatid disease was found. Postoperative course was uneventful and the patient was discharged on the tenth postoperative day with Albendazole (20 mg/kg). A histopathology report confirmed the diagnosis of a hydatid cyst.


   Discussion Top


Echinococcosis is an infectious parasitic disease that leads to cystic lesions of various organs and presents with various clinical features and surgical pictures including obstructive jaundice. However, the association of a hydatid cyst and jaundice is unusual, [3] the incidence of which isreported to be 5-17%. [2] An intrahepatic, hydatid cyst causing obstruction and compression of the intrahepatic biliary ducts resulting in jaundice is the usual form. [1],[2],[3] Extrahepatic biliary obstruction by a hydatid cyst is rare and is usually caused by the rupture of hepatic cysts into the biliary tract with resultant obstruction by the contents of the cysts. Extrahepatic biliary obstruction by hydatid cysts without hepatic involvement is the rarest form. [2] Till date, only one pediatric case with an extrinsic compression of the CBD has been reported. [2] A solitary extrahepatic cyst without any hepatic involvement, causing intrinsic obstruction of the CBD is unknown.

A choledochal cyst presents with the triad symptoms of intermittent jaundice, abdominal pain and an abdominal mass. [4] These clinical features associated with confirmatory USG and CT results prompted us to make a diagnosis of a type 1 choledochal cyst. However, in hydatid disease-endemic areas, the differential diagnosis of a hydatid cyst should be considered. [5] Though USG and CT are helpful to confirm the diagnosis of obstructive jaundice, they may not be helpful in the absence of other clues. [6],[7] Magnetic resonance (MR) cholangiography correlated with MR cross-sectional imaging can be useful to check the diagnosis of a misinterpreted choledochal cyst. [8] Atypical presentation of a hydatid cyst within a choledochal cyst has been reported [9] but a single hydatid cyst directly obstructing the CBD in the absence of any hepatic disease, is unique.

 
   References Top

1.Busic Z, Amic E, Servis D, Predrijevac M, Stipancic I, Busic D. Common bile duct obstruction caused by the hydatid daughter cysts. Coll Antropol 2004;28:325-9.  Back to cited text no. 1    
2.Otgun I, Karnak I, Haliloglu M, Senocak ME. Obstructive jaundice caused by primary choledochal hydatid cyst mimicking radiologically choledochal cyst. J Pediatr Surg 2003;38:256-8.  Back to cited text no. 2    
3.Machado A, Lozano A, Astete M, Watanabe J, Miyagui J, Velasquez H, et al . Endoscopic retrograde cholangiopancreatography and sphincterotomy in parasitic Diseases. Rev Gastroenterol Peru 1996;16:258-63.  Back to cited text no. 3    
4.Shian WJ, Wang YJ, Chi CS. Choledochal cysts: A nine-year review. Acta Paediatr 1993;82:383-6.  Back to cited text no. 4  [PUBMED]  
5.Durgun AV, Gorgun E, Kapan M, Ozcelik MF, Eryilmaz R. Choledochal cysts in adults and the importance of differential diagnosis. J Hepatobiliary Pancreat Surg 2002;9:738-41.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Kabaalioglu A, Arslan G, Ceken K, Melikoglu M, Sindel T, Luleci E. Common bile duct obstruction caused by hydatid cyst membranes: US and CT imaging. Pediatr Radiol 1998;28:328.  Back to cited text no. 6    
7.Goodman A, Harries-Jones EP, Lipinski JK. Two unusual causes of jaundice with similar ultrasound and CT findings. J Comput Assist Tomogr 1984;8:1110-3.  Back to cited text no. 7  [PUBMED]  
8.Govil S, Justus A, Korah I, Perakath A, Zachariah N, Sen S. Choledochal cysts: Evaluation with MR cholangiography. Abdom Imaging 1998;23:616-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Gangopadhyay AN, Sahoo SP, Sharma SP, Gupta DK, Sinha CK, Rai SN. Hydatid disease in children may have an atypical presentation. Pediatr Surg Int 2000;16:89-90.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1], [Figure - 2]


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    Abstract
    Introduction
    Case Report
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