Preoperative cholangioscopic identification of traumatic type IVa choledochal cyst perforation after motor vehicle collision: A case report

Background

Choledochal cyst (CC) perforation is a rare and potentially life-threatening complication of an uncommon congenital biliary abnormality. There are few case reports in adults, especially in settings of traumatic injury. In all reports of traumatic CC perforation, the diagnosis was made during emergent laparotomy. CASE SUMMARY A 63-year-old female with right upper quadrant and epigastric abdominal pain following a motor vehicle collision presented to the emergency room, with imaging suggestive of choledocholithiasis without hepatic injury. Endoscopic retrograde cholangiopancreatography (ERCP) and direct cholangioscopy revealed a contained hemorrhage secondary to a perforated bile duct, which raised suspicion for perforated CC. This prompted evaluation with cholangiogram, and a cholecystostomy tube bridge to surgical excision of CC and hepaticojejunostomy. Intraoperative anatomical classification of the cyst and surgical pathology confirmed a perforated Type IVa CC, which was treated with surgical excision and Roux-en-Y hepaticojejunostomy and cholecystectomy. Symptoms did not reoccur within a three month follow-up period.

Conclusion

This case highlights the diagnostic value of adding cholangioscopy to ERCP in identifying occult biliary injury in hemodynamically stable patients presenting with right upper quadrant abdominal pain in settings of trauma, which was supported by extravasation on cholangiogram. Utilization of these tools can lead to prompt perioperative recognition and management.