Pseudopancreatitis and choledochal cyst

E. Pareja Ibars, E. Artigues Sánchez de Rojas, F. Villalba Ferrer, R. Fabra Ramis, A. Vázquez Prado
and R. Trullenque Peris

Services of General Surgery and Digestive Diseases. Hospital General Universitario de Valencia, Spain

          

The congenital biliary duct cyst is a low-incidence illness. Alonso-Lej et al. was first to classify the different congenital choledocal cysts (1). Although it is considered a congenital illness, 30% of cases are diagnosed in the adult age.

Clinical symptoms are quite variable: the classical triad of abdominal pain, jaundice and abdominal mass is exceptional in adult subjects. This disease occasionally presents with epigastric pain, nausea, vomiting, fever, increased blood bilirubin, and increased blood amylase, suggesting the diagnosis of acute pancreatitis. However, this diagnosis that is not confirmed by imaging techniques or laparotomy studies. This form of clinical presentation of choledochal cysts has been designated pseudopancreatitis (4) or fictitious pancreatitis (3), which usually has a favorable outcome. In this report, we present two cases that clinically started with the aforementioned symptoms, and in which a diagnosis of congenital cystic dilatation of the common bile duct was finally established. No acute pancreatitis was confirmed. In both cases a surgical operation was performed with resection of the dilated bile duct and restoring biliary-enteric continuity using a Roux-en-Y hepaticojejunostomy (5). Results of this treatment was satisfactory in both patients.

This type of pathology is controversial as to whether increased blood amylase is due to a mild form pancreatitis or it is not caused by a acute pancreatitis (3,4). The clinical, anatomical and histological features of these cases support the role of pancreatic reflux and the obstructive component associated with the pathophysiology of choledochal cysts (5). Both the observation of normal pancreas during surgical laparotomy and the absence of morphological pancreatic alterations on radiologic imaging in our two cases support the latter option. Considering all this, the term “pseudopancreatitis” seems to be appropriate to define this characteristic manifestation of choledochal cysts.

REFERENCES

1. Alonso-Lej F, Rever W Jr, Pessagno DJ. Congenital choledochal cyst, with report of two, and analysis of 94 cases. Surg Gynecol Obstet 1959; 108: 1-30.

2. De Vries JS, De Vries S, Aronson DC, Bosman DK, Rauws EA, Bosn Hey HA, et al. Choledochal cyst: age of presentation, symptoms, and late complications related to Todani´s classification. J Pediatr Surg 2002; 37 (11): 1568-73.

3. Stringel G, Filler RM. Fictitious pancreatitis in choledochal cyst. J Pediatr Surg 1982; 17: 359-61.

4. Todani T, Urushihara N, Watanabe Y, et al. Pseudopancreatitis in choledocal cyst in children: intraoperative study of amylase levels of the serum. J Pediatr Surg 1990; 25: 303-6.

5. Okada A, Hasegawa T, Oguchi Y, Nakamura T. Recent advances in pathophysiology and surgical treatment congenital dilatation of the bile duct. J Hepatobiliary Pancreat Surg 2002; 9 (3): 342-51.