28 year old young lady with abdominal pain was diagnosed with a choledocal cyst – a congenital problem with abnormal shape and size of the bile duct / ducts. She had a large oval shaped common bile & hepatic duct with repeated inflammation causing symptoms like abdominal pain, fever & jaundice. She underwent a thorough work involving CT scan and MRI of abdomen. Later a surgery was performed, cyst / the entire abnormal portion of bile duct was excised and a loop of small intestine was joined to the liver side of the bile duct. Thus establishing the biliary drainage. The patient was discharged in 5 days and is free of complaints.
Choledocal cyst is congenital development problem involving the bile duct / ducts. It can affect the bile ducts outside the liver or inside the liver or both. Depending on the ducts involved and the shape there are many types and the treatment is guided by the type, symptoms & complications if any. Being a congenital problem, many patients are pediatric age group / children. However often the symptoms don’t occur in childhood or are neglected or problem is undiagnosed during basic investigations. So these patients may present in adulthood. Few patients with atypical choledocal cyst are picked up during routine health check up.
It may cause complaints like abdominal pain in right upper abdomen, fever and jaundice due to inflammation and infection. Often a lump / mass is felt in the right upper abdomen. Sometimes stones or cancer may develop in the cyst and cause obstruction causing any of the above mentioned complaints. Many patients are asymptomatic.
When a patient is diagnosed with choledocal cyst, he / she is further investigated if there are symptoms as the treatment is warranted only if there are symptoms, stones or cancer. Every choledocal cyst is not treated. The important investigations include MRI / MRCP (noninvasive cholangiogram / visualization of the bile ducts) & CT scan of abdomen. Invasive investigations like ERCP (endoscopic visualization of bile ducts), PTC (radiological percutaneous intervention to see bile ducts) is avoided for the fear of causing complications like infection. Only when there is preexisting infection, ERCP / PTC is done to drain (insert a stent / tube) the cyst / bile duct to reduce infection.
The treatment as mentioned before is decided by the type of cyst. For the fear of causing confusion in the mind of a layperson reading this information, we are not going into the details. It will suffice to say that the treatment should be decide by a specialist. Patient with involvement of only the ducts outside the liver, surgery is performed wherein the involved portion is removed as in our case and intestine is joined to the cut end of bile duct. When the ducts inside the liver are affected, it may need a liver resection. In another type (diverticulum) only the cyst is excised without harming the other ducts. If only the lower end of the common bile duct is involved (choledococele), endoscopic treatment option is available. If there is cancer in the choledocal cyst it is treated as per the principles of treatment of bile duct cancer which is discussed elsewhere.