1. Speaker: 呂佳興 Supervisor: 蔡宏名老師 Dr. 孫明祥醫師
Intern seminar
Speaker: 呂佳興
Supervisor: 蔡宏名老師
Dr. 孫明祥醫師

2. Personal identifies Name: 林xx Age : 6 years old Gender: female
Date of admission: 2005/02/04

3. Present illness
Referred to　Dr.林炳文，abdominal echo, MRI, blood test was done.
No fever, no jaundice.
Intermittent abdominal pain especially after lunch
2005/01/31
2 months ago
4 months ago
1 month ago
Referred to Dr.陳肇真
Admitted then.
Visited GI LMD

4. Past history 1. Neonatal jaundice s/p phototherapy
2. No history of surgical operation
3. No other major medical problems
4. No known drug allergy
Family history:
Not contributory

5. Physical exam-1 Consciousness: clear
Vital sign: stable and within normal range.
HEENT: conjunctiva: not pale
sclera anicteric
light reflex +/+
Neck: supple, no LAP, no JVE

6. Physical exam-2 Chest: clear breathing sound in both lungs
Heart sound: regular, no murmur
Abdomen:
soft, normal active bowel sound
peri-umbilical pain described by patient.
Diffuse tenderness when palpated.
Extremities: freely movable, no edema

7. Lab Data item result Normal range GOT 23 5-40 GPT 10 5-55 Bil-T 0.4
Bil-D
0.1
<0.4
ALK-P
178
110
GGT 80

8. Echo on 2005/01/03

26. What’s your findings

27. 1.Normal liver parenchymal echo pattern without
abnormal focal space-occupying lesions is found.
2.The GB is well distended with normal wall
thickness.
3.There is a dilated outpouching of extrahepatic
duct with some stones. The IHDs are patent.
The PV is patent.
4.The pancreas is normal in size and echogenicity.
5.The spleen is normal in size.
6.No abnormal lymph node enlargement is found.
7.Bil. kidneys are unremarkable.
看完ｅｃｈｏ上報告的形容，我們再來看MRI驗証一下

28. MRI image

45. MRCP

52. What’s your finding

53. Diagnosis Sonography: Clinical information: choledocal cyst
IMP:R/o choledochal cyst with some stones.

54. MRI with and without contrast
1. MR cholangiography showed marked dilated CHD and proximal to middle CBD,about 35mm in caliber. The distal CBD and IHDs are preserved. The pancreatic duct is not dilated. GB is distended with smooth in wall.
2. The liver,spleen and both kidneys are normal in size and shape.
3. The pancreas is normal in size.
4. The stomach is not distended,but no evidence of abnormality.
5. No para-aortic lymph node can be seen.
IMP: Choledochal cyst, type I.

55. Operation note

57. Pathology report Pathology: choledocal cyst +chronic cholecystitis
CBD fluid: amylase: 91500u/L
lipase: u/L
bil-T/D: 546/0 mg/dL

58. Post-op care No fever, no jaundice WBC: 8.1 Seg: 72.9 % CRP: 54
Serum biochemistry within normal range.
MBD on post-op day three

68. 1.Normal liver parenchymal echo pattern without abnormal focal space-occupying lesions.
2.The GB is absent.
3.The biliary system is patent. The PV is patent.
4.The pancreas is normal in size and echogenicity.
5.The spleen is normal in size.
6.No abnormal lymph node enlargement is found.
7.The Bil. kidneys are normal in size and position.
8.The echogenicity of bil. kidneys is not increased.
9.The bil. renal parenchymal thickness is preserved.
10.No abnormal hyperechoic focus in bil. collecting systems.
11.No abnormal dilatation of the bil. collecting systems.
12.No abnormality over aorta and IVC areas.
IMP:s/p cholecystectomy.
孫明祥醫師-

69. Differential diagnosis
1. obstructive bile duct dilatation
2. hepatic artery aneurysm
3. biloma
4. pseudocysts and cysts of abdomen

70. Differential diagnosis 1. obstructive bile duct dilatation
1. obstruction site (stone, stenosis)
2. smoothly dilated ducts
3. dilated intra-hepatic ducts
4. markedly elevated alkaline phosphatase.

71. Differential diagnosis 2. hepatic artery aneurysm
1. hepatic artery origin
2. medical history may hints
3. color doppler to detect blood flow.

78. Differential diagnosis 3. biloma
1. history
2. location

82. Differential diagnosis 4. pseudocysts and cysts
1. trace the cyst origin, see if any communicating with the biliary system
2. history
3. stone is uncommon in cysts

83. Choledocal cyst Dilatation of bile ducts. Old name of biliary cyst
Specially referring to extra-hepatic cysts
Prevalence: 1/2000,000~~1/1,3000
much higher in Asian countries
female: male: 3:1

84. Choledocal cyst-- Etiology
congenital V.S. acquired
infectious agents
reflux of pancreatic enzymes
long common channel
genetic factors, and
biliary autonomic dysfunction.
abnormal pancreaticobiliary junction (APBJ) is present in about 70 percent of patients
some may show family history

85. Stone
abnormal pancreaticobiliary junction

87. dilatation of extra-hepatic duct accounts for 50- 85%
Type I
dilatation of extra-hepatic duct accounts for %

88. Type II
Saccular outpouching of the common bile duct.

89. Type III Type III is also named choledochocele
wide mouth dilation of the common duct at its confluence with the duodenum.
Lined with duodenum epithelium
Not associated with biliary tract carcinoma

90. Type IV Second common type 33%
Cystic dilatation of both intra and extra hepatic ducts

91. Type V multiple intrahepatic cysts with no extrahepatic component
Termed caroli’s disease when associated with hepatic fibrosis and medullary sponge kidney
Caroli’s disease is autosomal recessive.
Malignancy 7%

99. Clinical findings Clinical triad: RUQ mass 30-60% jaundice 80%
abdominal pain >90%
Gallstones, cholangitis, cholecystitis, pancreatitis, biliary peritonitis. Biliary cirrhosis. abscess
Cholangiocarcinoma
0.7% at first 10 years
6.8% at 20 years old
14.3% over age 20
increase even further through life, up to 50%

100. Image findings
1. dilated bile duct seen from echo, CT, MRI, or cholangiography.
2. abnormal pancreaticobiliary junction may be seen (elongated, dilated)
3. colangiography is the best test for choledocal cysts.

101. treatment Roux-en-Y hepaticojejunostomy (draining in old days)
Type IV may require partial hepatectomy
Long term complications
anastomose stricture(25%) and it’s consequence
intrahepatic stone

102. references 1. Lawrence W. Way: Way Current Surgery
2. uptodate online database
3. Harrison online
4. Radiographics. 2001;21:
Cystic Focal Liver Lesions in the Adult: Differential CT and MR Imaging Features

103. Thanks for your attention