대한췌담도학회 월례집담회 2011. 06. 04 CASE PRESENTATION Sang Koo Kang, Tae Hoon Lee, Sang-Heum Park Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital.

Chief complaints Recurrent epigastric pain onset) 2 months ago Past history : DM(-), HTN(-) Alcohol(-), Smoking(-) Operation history(-)

Present illness A 24-year-old man presented with recurrent abdominal pain that had started to worsen two months before P. Ex.: mild tenderness on epigastrium

Laboratory test WBC: 6.30 X 109/L, Hb:14.2 g/dL T-bilirubin: 1.1 mg/dl AST: 28 IU/L, ALT: 13 IU/L Amylase: 115 IU/L, lipase: 45 IU/L Alkaline phosphatase: 61 IU/L, GTP: 28 IU/L CEA: 4.05 ng/ml, CA19-9: 23.68 U/ml hs-CRP: 0.3 mg/L

Abdomen CT

MRCP

Initial diagnosis Impacted stone in cystic duct or periampullary diverticulum CBD compression Therapeutic plan: ERCP

ERC

Initial diagnosis II Impacted cystic duct stone R/O Mirrizzi’s syndrome Therapeutic plan  Laparoscopic cholecystectomy

Operation Laparoscopic cholecystectomy Conversion to laparotomy  Enuclation of an impacted stone by incision negotiated the cystic duct and CBD, but could not find connecting cystic duct and previously inserted plastic stent Conversion to laparotomy  the saccular dilatated cystic lesion of CBD  choledochal cyst excision with Roux-en Y hepaticojejunostomy

Histologic finding

Final diagnosis Choledochal cyst type II with a large impacted stone; masqueraded as a impacted cystic duct stone