Spontaneous gangrene and perforation of choledochal cyst: a rare presentation

Abstract

Choledochal cyst is a rare entity. It generally presents in children with pain, jaundice and the occasional finding of a lump in right hypochondriac region. A very rare presentation is biliary peritonitis resulting from a perforated choledochal cyst. It is usually seen in younger children. Our patient was a 14 year old female who presented with an acute abdomen. Clinically she had signs of peritonitis. Chest radiograph did not show free gas under diaphragm. The USG showed a dilated CBD of 4.1cm with a calculus at its lower end of 2 x 2.6cm, USG guided diagnostic tap revealed bile. Emergency exploration was done, a gangrenous patch of size 3 * 2cm in the anteromedial wall of large choledochal cyst was found with a perforation in it. No calculous was found. The gangrenous wall of choledochal cyst was excised and primary suturing of choledochal cyst was done with a T-tube placed through separate incision in choledochal cyst. As there is no facility for intra-operative cholangiogram in the emergency setting in our institute, a post-operative cholangiogram was done on day 7. It revealed a dilated CBD, CHD as well as right and left hepatic ducts (choledochal cyst type IA). The patient was discharged and asked to follow-up electively for excision of choledochal cyst at a later date. A rare possibility of a perforated choledochal cyst should be kept in mind in cases of biliary peritonitis, especially in younger age groups. Bile drainage would be a safer procedure in emergency condition, especially when patient presented late to hospital with hemodynamic unstability and edematous wall.