1. 대한췌담도학회 월례집담회 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.

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

3. 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

4. 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: U/ml
hs-CRP: 0.3 mg/L

5. Abdomen CT

6. MRCP

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

8. ERC

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

10. 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

12. Histologic finding

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