Duplication of the common bile duct A case Duplication of the common bile duct...

Duplication of the common bile duct A case Duplication of the common bile duct ¢â‚¬â€œA case report 1 Department
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Transcript of Duplication of the common bile duct A case Duplication of the common bile duct...

  • Duplication of the common bile duct – A case report

    1 Department of Surgery, Spital Linth, Uznach, Switzerland, 2 Department of Medicine, Gastroentrology, Spital Linth, Uznach, Switzerland, 3 Department of Radiology, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland

    Anatomical variants of the extrahepatic bile duct system occur in

    approximately 42% of the population. On the other hand, duplication of

    the common bile duct is a very rare congenital abnormality, which is

    often associated with recurrent cholangitis or pancreatitis, as well as

    an increased risk of malignant degeneration. Therefore diagnostics

    using MRI and ERCP as well as the therapeutic strategy are a

    challenge. Classification and division according to Choi et al. describe

    5 different types of anatomical variants of the common bile duct. Our case presents a patient with a duplication of the DHC type Vb (Fig. 1).

    Introduction

    We have treated a 50-year-old woman, who presented herself with

    severe coliform epigastric pain and febrile temperature. The gall

    bladder has been removed several years ago due to severe

    cholecystitis with cholecystolithiasis. A cholestatic hepatopathy was

    found as well. However the duplication of the common bile duct was

    not detected. At present the patient showed increasing inflammation

    values under antibiotic therapy and the suspicion of cholangitis.

    Case Report

    The performed MRCP showed a duplication anomaly (Fig. 2a) and a

    choledocholithiasis (Fig. 2b) of the right common bile duct.

    The following ERCP procedure for stone removing was only partially

    successful. After recurring of inflammatory and cholestasis parameters, the

    choledochus duplicate was resected (Fig. 3) by means of biliodigestive

    anastomosis. Intraoperatively, a massive dilated ductus hepatocholedochus

    is shown, as well as a slender left main bile duct (Fig.4a,b). After resection of

    the right bile duct on the pancreatic upper edge, the latter measures 2 cm in

    diameter (Fig.4a,b). The intraoperative preparation follows the two bile ducts

    up to cranial, which is continued into the normal intrahepatic bile duct system

    (Fig.1). Immediately proximal to the communicating connection between the

    two ducts, the resection occurs at the border to the intrahepatical normal bile

    duct system and attachment of a biliodigestive anastomosis by means of a

    retrocolitical pulled Roux-Y jejunal loop.

    There was an uncomplicated postoperative course with an antibiotic therapy

    administered over 10 days, because of the existing cholangitis. Histology

    showed no signs of malignancy.

    The final control 14 days postoperatively was inconspicuous with a decrease

    of transaminases. One month after operation the patient was already 20%

    more workable, after another month the patient worked at full capacity.

    Results

    In patients with recurrent cholangitis an anatomical variant must be considered, especially after removing the gall bladder and the lack of complete recovery. In the

    rare cases of types Va (5) and Vb (1) is a risk of malignancy up to 25%, as well as frequently occurring complicated choledocholithiasis. Therefore according to recommended literature the preoperative diagnosis is essential for the planning of the therapeutic strategy by means of biliodigestive anastomosis.

    Conclusion

    A. Schulz1, F. Boxberger2, A. Heinle3, S. Schär3, C. von der Lippe1, F. Hetzer1

    Fig.1

    Duplication of the common bile duct system

    type Vb, schematic presentation

    1. Arora A. et al. Common bile duct duplication: The more the murkier. Saudi J Gastroenterology 2015;2:51-4

    2. Hammad T. et al, Two cases of Type Va extrahepatic bile duct duplication with distal Klatskin Tumor surgically treated with Whipple procedere and Hepaticojejunostomy, ACG Case Rep J 2015 ;3 (1) : 49-52

    3. Kim S.W. et al. Duplication of the extrahepatic bile duct in association with choledocholithiasis as depicted by MDCT, Korean J Radiol 2008; 9 : 550 – 554

    4. Gupta V., Chandra A., Duplication of the extrahepatic bile duct, Congenital Anomalies 2012; 52, 176 - 178

    References

    Fig.2b MRCP coronal slice,

    on the left side Ductus hepatocholedochus dexter with a Choledocholithiasis,

    on the right side Ductus hepatocholedochus sinister without stones

    Fig.2a

    MRCP axial slice, showed

    the duplication of the

    common bile duct

    Fig.3 Intraoperative situs

    Fig.4 Resection of the duplication with the blue marked dilated right common bile duct;

    a closed, b open

    a b