CholedochalCysts : CholedochalCysts And Imaging the Biliary Tree Karl Langberg Choledochal Cysts : Choledochal Cysts Rare congenital abnormality of the biliary tree
Dilation of a portion of the bile duct
Affects 1 in 13,000 to 1 in 2,000,000
Present in girls 3 times more than boys
Causes 2%-5% of extrahepatic neonatal jaundice
20% become symptomatic in adulthood Presentations & Associations : Presentations & Associations Intermittent RUQ pain
Distention/ inflammation of a portion of the biliary tree
Dilated extrahepatic bile duct
Increased risk for Cholangiocarcinoma
Consequence of cholestasis Classic Triad Work Up & Diagnosis : Work Up & Diagnosis Choledochal cysts usually diagnosed by Imaging
Screening is done with ultrasound
Follow up with Endoscopic Retrograde Cholangiopancreatography (ERCP)
Magnetic Resonance Cholangiopancreatography (MRCP) is an increasingly common, accurate (96%), diagnostic modality. ERCP : ERCP Endoscopic technique
Has both diagnostic and theraputic roles ERCP : ERCP Injects contrast into the biliary tree to visualize the anatomy in real time with fluoroscopy Slide 9: A) D) C) B) Benefits and Risks : Benefits and Risks Interventions by ERCP can avoid the need for surgery
Complications occur in 5%-7% of patients. They include: Pancreatitis (4%), Hemorrhage (1%), Cholangitis (1%), Perforation (0.5%) and Death (0.1%)
ERCP’s use as a diagnostic measure is decreasing due to a less invasive way to image the biliary tree MRCP : MRCP Noninvasive MR imaging of the biliary tree Quick MR basics : Quick MR basics Hydrogen nuclei have a magnetic orientation
MR uses a giant magnet to line all of the H atoms in the same orientation
Rf pulses return the atoms back to equilibrium, releasing energy into the surrounding tissues
The rate of this energy dissipation is different for different tissues Study Types : Study Types Different remagnetization properties of the H atoms in certain tissues can be analyzed with two main study types
This allows for different pictures of the same tissue to tell certain properties of that tissue. T1 : T1 Fluid appears dark
Fat appears light CSF Grey mater White mater T2 : T2 Fluid appears light
Fat appears dark CSF White mater Grey mater MRCP : MRCP Heavily T2 weighted study
Easily images the relatively stationary bile that fills the biliary tree
Provides high quality picture of patient’s anatomy
Has no theraputic role but is non invasive Classification of Choledochal Cysts : Classification of Choledochal Cysts There are 5 subtypes of choledochal cysts.
Classified based on morphology of the dilatation Normal Anatomy : Normal Anatomy ERCP Endoscope MRCP Intrahepatic Bile Duct Gall Bladder Extrahepatic Bile Duct Sphincter of Odi Hilar confluence Case Presentation : Case Presentation 61 year old Asian woman
CC: RUQ pain, nausea, alternating diarrhea and constipation
HPI: Sx occurred intermittantly 4-5 years ago. Choledochal cyst diagnosed by ultrasound. Sx have become constant.
PMH: Gall bladder cancer (has been removed), breast cancer with bone metastasis, Heart disease, sleep apnea, diabetes, HTN, 5 cm Ascending Aortic Aneurism. Continued : Continued An ERCP was performed ˜ : ˜ ERCP : ERCP Diffuse dilatation of common bile duct
Distended up to the left hepatic duct
No contrast dye filling defects MRI with MRCP : MRI with MRCP Performed to confirm diagnosis MRI with MRCP : MRI with MRCP MRI with MRCP : MRI with MRCP MRI with MRCP : MRI with MRCP MRI with MRCP : MRI with MRCP MRI with MRCP : MRI with MRCP MRI with MRCP : MRI with MRCP Diagnosis- TypeI Choledochal cyst : Diagnosis- TypeI Choledochal cyst Most common classification
80%-90% of Choledochal Cysts Slide 33: X X X X X X X X X Treatment : Treatment Surgical excision and reanastomosis
Must weight pros and cons of surgery vscholangiocarcinoma risk and symptoms
Drain cyst of biliary sludge Other Types : Other Types Type 2
Diverticulum of CBD
Cyst of the intraduodenal duct
Choledococele Other Types : Other Types Type 4
Both intra and extrahepatic involvement
Intrahepatic involvement only
Caroli’s disease Shout Outs : Shout Outs Special Thanks to
Dr. Diego Martin
Dr. Bobby Kalb
Dr. Jimmy Costello Refrences : Refrences Sokol Ronald J, Narkewicz Michael R, "Chapter 21. Liver & Pancreas" (Chapter). Hay WW, Jr., Levin MJ, Sondheimer JM, Deterding RR: CURRENT Diagnosis & Treatment: Pediatrics, 19e: http://www.accessmedicine.com/content.aspx?aID=3404306.
MorteleKoenraad J, "Chapter 9. State-of-the Art Imaging of the Gastrointestinal System" (Chapter). Greenberger NJ, Blumberg RS, Burakoff R: CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy: http://www.accessmedicine.com/content.aspx?aID=6201030.
Carr-Locke David L, "Chapter 35. Endoscopic Retrograde Cholangiopancreatography (ERCP)" (Chapter). Greenberger NJ, Blumberg RS, Burakoff R: CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy: http://www.accessmedicine.com/content.aspx?aID=6203876.
Greenberger Norton J, Paumgartner Gustav, "Chapter 305. Diseases of the Gallbladder and Bile Ducts" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17e: http://www.accessmedicine.com/content.aspx?aID=2874111.
Chen Michael Y, Bradbury Michelle S, "Chapter 1. Scope of Diagnostic Imaging" (Chapter). Chen MYM, Pope TL, Jr., Ott DJ: Basic Radiology: http://www.accessmedicine.com/content.aspx?aID=2270000.
ShethKetan R, Bonnor Ricardo M, Pappas Theodore N, "Chapter 45. Biliary Tract" (Chapter). Zinner MJ, Ashley SW: Maingot's Abdominal Operations, 11th Edition: http://www.accesssurgery.com/content.aspx?aID=130494
Wikipedia: Choledochal cysts, for some images