Nena A. Stanley, MS IV Wayne State University School of Medicine December 19, 2008 History HPI: 83 yo male with a PMH dementia, DMII, HTN, atrial fibrillation presented to ER after episode of syncope. Pt. stated he became dizzy in the bathroom and lost consciousness. Patient stated had experienced one past episode of syncope two weeks prior which he sought no treatment. Associated symptoms (+)loss incontinence (+)clay-colored stool, (+) coluria, (+)dizziness, (+)jaundice, (+)HA, (+)30 lb wt loss, (-)fever, chills, nt. sweats, (- )recent head trauma, (-)nausea, (-)vomiting, (-)blurred vision, (- )tinnitus, (-)palpitations, (-)dyspnea on exertion, (-)orthopnea, (- )edema, (-)SOB, (-)hemoptysis, (-)loss of appetite, (- )melena, (-)hemetemesis, (-)hematuria, (-)dysuria, (-) anemia, (-)numbness/tingling of extremities History continued PMH/PSH: Dementia, DMII, HTN, a-fib, MI, mitral valve replacement FH: Noncontributory SH: Married with 3 adult children, lives at home, (-)smoking, (-)EtOH, (-)recent travel, (-)illegal drug use MEDS: Coumadin, Digitoxin, Humulin (70/30), Motrin ALL: NKDA History continued Labs: INR 6.45, elevated liver enzymes (SGOT: 498.0 U/L; SGPT:306 U/L; T.Billi 22.2 mg/dl; Bili D 11.6 mg/dl; Alk Phos: 1,281 U/L) A/P Abdominal US to rule out obstructive jaundice Findings Ultrasound with Doppler Intrahepatic duct and common bile duct dilation Slightly distended gallbladder with visible sludge Unable to visualize pancreas CT of abdomen recommended to visualize pancreas and further evaluation of biliary ducts Findings continued CT of Abdomen Nodular intrahepatic biliary dilation greater in left hepatic lobe Diffuse fusiform dilation of the common hepatic and bile duct measuring up to 3.9 cm Findings compatible to type Iva choledochal cysts No pancreatic cyst ERCP and/or MRCP recommended to exclude an underlying biliary or ampullary lesion Findings continued ERCP Significant intra and extrahepatic duct dilation Recognized stricture within the mid-common bile duct Differential Diagnosis Hepatic Cysts Choledochal Cysts Cholangiocarcinoma Choledocholithiasis Cholangitis Duplicated Gallbladder Diagnosis Choledochal Cysts Discussion Classification Type I is the most common and is a dilation of the common bile duct Type II is the rarest and is a diverticulum of the extrahepatic bile duct proximal to duodenum Type III is a choledochal from embryological origin and cystic dilation of intraduodenal portion of the distal common bile duct Type A bile duct and pancreatic duct converge on the cysts Type B is diverticulum of the intraduodenal bile duct or common bile duct Type IV multiple cysts Type IVA multiple intra and extrahepatic cysts Type IVB multiple extrahepatic parenchyma Type V multiple cysts limited to intrahepatic parenchyma Discussion continued Frequency Rare in U.S. More prevalent in Asia Mortality/Morbidity Age dependent Cholangiocarinoma malignancy 9-28% Sex Female prevalance 3:1 Discussion continued Management/Treatment Stent placement to correct stricture within the mid-common bile duct Surgical excision of cysts and resection of common biliary tract and duodenum Biopsy of cystic tissue to evaluate for dysplastic changes References DeGroen, Piet C., Biliary Tract Cancers, NEJM, 1999, Vol 341, No. 18 1368-1377 Novelline, Robert A. Novelline, Squires’s Fundamentals of Radiology, 6th Ed., Harvard University Press, Cambridge, MA: 2004 Sawyer, Michael AJ, Choledochal Cyst, e- medicine: April 13, 2007 Topazian, Mark, Biliary Cysts, Up to Date, v. 16.3: Oct. 1, 2008