Congenital biliary dilatation: a spectrum of disease detailed by ultrasound

Imaging in acute abdomen

OBJECTIVE

The present study aims at establishing the exact role and limitation of ultrasound in pediatric acute abdomen.

METHODS

Fifty children less than 14 years of age presenting with acute abdomen were evaluated by US and other imaging modalities. The mean age of presentation was 3 1/2 years. Maximum number of cases were seen in less than two years of age. There were 17 cases of intussusception with US sensitivity and specificity of 88.2% and 100% respectively and positive and negative predictive values of 100% and 94.5% respectively. There were 13 cases of appendicitis. US was diagnostic in 11 with sensitivity and specificity of 91.6% and 97%; the positive and negative predictive values were 91.6% and 97% respectively.

RESULTS

There were two cases each of congenital bands, adhesive intestinal obstruction, malrotation of bowel with volvulus, incarcerated inguinal hernia, hypertrophic pyloric stenosis, duplication cyst and pseudopancreatic cyst, one case each of trichobezoar, Meckel's diverticulum, ureteric calculus and worms as a cause of intestinal obstruction. The sensitivity of US for diagnosing specific cause of acute abdomen was found to be 77.5%. The main limitation of US was in the diagnosis of acute intestinal obstruction such as congenital bands and adhesions.

CONCLUSION

US should now be considered as imaging modality of choice in pediatric acute abdomen. However, at times, plain radiography, conventional contrast studies and CT may be vital to reach the true diagnosis.

Hepatobiliary scan showing type II choledochal cyst

Nuclear medicine hepatobiliary scintigraphy is well established for the evaluation of right upper quadrant pain in cases of possible acute cholecystitis. The authors present a case of type II choledochal cyst shown on a hepatobiliary scan in a patient with possible acute cholecystitis.

US approach to jaundice in infants and children

High-resolution real-time ultrasonography (US) serves as an important tool for differentiation of obstructive and nonobstructive causes of jaundice in infants and children, independent of liver function. Unconjugated hyperbilirubinemia occurs in approximately 60% of normal term infants and in 80% of preterm infants. Persistence of neonatal jaundice beyond 2 weeks of age demands US evaluation to differentiate between the three most common causes: hepatitis, biliary atresia, and choledochal cyst. In all three conditions, the hepatic echotexture is diffusely coarse and hyperechoic, but this appearance may be seen in a variety of hepatic inflammatory, obstructive, and metabolic processes. Thus, hepatic scintigraphy and at times percutaneous liver biopsy are necessary to narrow the differential diagnosis and to identify patients who require more invasive techniques (eg, intraoperative cholangiography). US is useful for demonstrating inspissated bile and biliary duct stones. In infants, stones are usually secondary to obstructive congenital anomalies of the biliary tract, total parenteral nutrition, furosemide treatment, phototherapy, dehydration, infection, hemolytic anemia, and short-gut syndrome, whereas in older children, stones are usually associated with sickle cell disease, bowel resection, hemolytic anemia, and choledochal cyst. Jaundice in infants and children may also be due to cirrhosis, benign strictures, and neoplastic processes.

Cholangiocarcinoma in Association With Caroli's Disease

Caroli's disease is a rare congenital disorder characterized by focal or diffuse dilatation of the intrahepatic bile ducts. If asymptomatic, this condition may remain undetected for several years. We present a case of focal Caroli's disease, first suspected on sonography, with a coexisting bile duct carcinoma. Both computed tomography (CT) imaging and percutaneous transhepatic cholangiography (PTC) supported a diagnosis of Caroli's disease but did not detect the presence of an associated mass, which was histologically proved to be a bile duct carcinoma. The advantages and disadvantages of different modalities in evaluating Caroli's disease are discussed.

Characteristics of infantile cases of congenital dilatation of the bile duct

PURPOSE

This study was performed to clarify whether infants with congenital dilatation of the bile duct (CDBD) have any specific characteristics in comparison with older children.

METHODS

Of 153 cases with CDBD treated at our institution between 1959 and 1997, 34 (22.2%) were infants less than 1 year of age. The control group consisted of 46 children between 1 and 4 years of age. Symptoms, laboratory data, and histological findings were compared between these two groups.

RESULTS

As the initial symptoms, abdominal pain was not present in infantile cases, with a significant difference from the older children, and a significantly higher incidence of abdominal mass and acholic stools was noted in infantile cases. Laboratory data of serum aspartate transaminase and amylase level and amylase concentration in the bile of the common bile duct were significantly lower in the infant group than in the older children. The ratio of morphological type of cystic to cylindrical dilatation was 33 to 1 in infants with a significant difference from the control group.

CONCLUSION

Infantile cases of CDBD, which mostly have cystic type dilatation, in contrast to older children, are likely to present with abdominal mass. Pancreatitis with abdominal pain related to reflux of pancreatic juice into the biliary duct appears to be uncommon in infantile cases.

[Problems in diagnosis and surgical therapy of choledochus cysts. A case report]

We report a case of choledochal cyst accompanied by an adenoid gallbladder carcinoma, in an adult patient. Diagnosis was complicated by coexisting primary hyperparathyroidism. In view of the pathological laboratory tests, which suggested acute pancreatitis, the visualized cystic abdominal mass was regarded as a pancreatic pseudocyst. Neither ultrasound nor CT could clearly define the cyst's origin. Laparotomy, performed later because of deteriorating clinical condition, showed an extended carcinoma which was already invading the liver. Only palliative resection and choledochocystojejunostomy was technically feasible. To prevent the development of malignancies in dilated bile ducts, early treatment by cyst resection and reconstruction of the extrahepatic biliary system is recommended, especially in younger patients.

Choledochal cyst disease. A changing pattern of presentation

OBJECTIVE

The authors compared the presentation, treatment, and long-term outcome of children and adults with choledochal cysts.

SUMMARY BACKGROUND DATA

The typical patient with choledochal cyst disease has been the female infant with the triad of jaundice, an abdominal mass, and pain. However, the recent experience of the authors suggested that the disease currently is recognized more commonly in adults.

METHODS

Forty-two patients (11 children, 32 adults) with choledochal cyst disease were treated primarily at this institution between 1976 and 1993. Patients presentation, clinical evaluation, and operative treatment were obtained from existing records. Long-term follow-up was obtained by records, physician, or direct patient contact.

RESULTS

One child--but no adults--had the classic triad of jaundice, abdominal mass, and pain. Children were more likely to have two of the three signs or symptoms (82% vs. 25%; p = < 0.05). Adult patients most commonly had abdominal pain and were thought to have pancreatitis (23%) or acute biliary tract symptoms, prompting cholecystectomy (50%). The type of choledochal cyst seen in children and adults was similar; the fusiform extrahepatic (Type I) was most common (50%), and the combined intrahepatic and extrahepatic (Type IVA) was the next most prominent (33%). For both children and adults, treatment consisted of excision of the cyst and biliary reconstruction with a hepaticojejunostomy. There was no surgical mortality. Gallbladder or cholangiocarcinoma was identified in three adults (9.7%), two of which were manifest on presentation. Long-term follow-up revealed one patient with a biliary stricture and three patients with Type IVA cysts who had intrahepatic stones.

CONCLUSIONS

Children and adults differ in presentation of choledochal cysts, with adults commonly having acute biliary tract or pancreatic symptoms. Surgical treatment with cysts excision and biliary bypass is safe and effective in children and adults with excellent long-term results that minimize the development of malignancy.

Choledochal cysts: a nine-year review

Hospital records of 24 Chinese infants and children (7 males and 17 females) with choledochal cysts were reviewed. The patients were aged 1 day to 17 years. Abdominal pain, palpable abdominal mass and jaundice, either alone or in combination, accounted for most of the initial presentations. Twenty-two patients were classified as type I with surgery, while the other two patients were type V without surgery. Ultrasonography is a rapid and accurate diagnostic method in the initial evaluation. Cyst excision with Roux-en-Y hepaticojejunostomy was the treatment of choice in this series. Chronic cholecystitis with or without inflammation of choledochal cyst was the most common pathological finding. Five patients underwent liver biopsies, showing four biliary cirrhosis and one portal fibrosis. So far, there is no evidence of malignancy in any patient.

Choledochal cyst

Since 1959 when Alonzo-Lej and colleagues introduced the modern era of treatment of choledochal cysts, much information has come to light, particularly from Japan where the incidence of choledochal cyst is much higher than in occidental countries. While the original classification of Alonzo-Lej is still in use, additional forms of the anomaly have been identified by modern imaging techniques. Antenatal ultrasound studies and accurate cholangiography have made it possible not only to better define these anomalies but also to provide information regarding etiology. It seems most likely that choledochal cysts are the result of pancreatic reflux into the biliary tree from an anomalous junction of the main pancreatic duct with the common bile duct. Ultrasound, radioscintigraphic studies, and various forms of cholangiography have made the diagnosis straightforward. Although many approaches to treatment have been tried over the years, the most successful approach is total cyst excision with Roux-en-Y hepaticojejunostomy. This provides excellent long-term results with minimal complications. Nonetheless, lifelong follow-up is necessary to avoid potential problems such as biliary cirrhosis. Other forms of choledochal cysts, such as choledochocele and Caroli's disease, are treated as the anatomy dictates and these individuals must be followed long term as well. The overall results are most gratifying.