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Cases
Toddler With a Clinical Diagnosis of Intussusception
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Background
A 2-year-old toddler presents with episodes of severe, intermittent, colicky abdominal pain, during which he draws up his legs. The boy has no past history of illness.
Physical examination reveals a palpable, tender, and ill-defined mass on the right side of his abdomen. The patient also has mild pyrexia, tachycardia, and mild leukocytosis. Laboratory tests reveal that levels of the inflammatory markers and bilirubin levels are mildly elevated. These findings suggest intussusception.
Imaging studies are performed. What is the diagnosis?
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Scroll
down for Hint and Answer
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***** HINT *****
Why is the bilirubin level elevated? The sonographic findings establish the diagnosis.
***** ANSWER *****
Type I choledochal cyst complicated by acute pancreatitis: The sonogram in A reveals 1.6-cm focal dilatation of the distal common bile duct, with proximal intrahepatic biliary dilatation. An additional image shows free fluid in the Morrison pouch and the pelvis (B) but no evidence of intussusception. These findings are characteristic of a choledochal cyst.
The palpable mass is a grossly distended gallbladder. The free fluid is secondary to acute pancreatitis, which is a recognized complication of choledochal cyst.
At a tertiary center, the boy underwent further investigations, including a serum amylase determination, the findings of which confirmed acute pancreatitis. He also underwent magnetic resonance cholangiopancreatography (MRCP) prior to surgery. The coronal images also confirmed a choledochal cyst with a distended gallbladder. The axial images in C and D show features of a type I choledochal cyst and gallbladder with intrahepatic biliary dilatation. The patient was surgically treated for his choledochal cyst.
The classic triad of abdominal pain, jaundice, and a palpable mass in the right upper quadrant is seen in less than 30% of patients with choledochal cysts. Other complications in children include cholangitis, cyst rupture, biliary peritonitis, and biliary cirrhosis. In adults, the most serious complication is cholangiocarcinoma (incidence >40%), which occurs if the cyst is left untreated. Therefore, prompt diagnosis and surgical treatment are essential.
For more information on choledochal cysts, see the eMedicine articles Choledochal Cyst (within the Radiology specialty), Choledochal Cysts (within the Internal Medicine specialty), and Choledochal Cyst: Surgical Perspective (within the Pediatrics specialty).
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Author:
Ali Nawaz Khan,
MBBS, FRCP, FRCS, FRCR, Lecturer, Department of Diagnostic Radiology, Faculty of Medicine, University of Manchester, and Prabhakar Rajiah, MD, FRCR, Registrar, Department of Radiology, North Manchester General Hospital NHS Trust, UK
North Manchester General Hospital, Crumpsall, Manchester M86RB, UK
eMedicine Editor:
Sat Sharma, MD
Associate Professor, University of Manitoba, Department of Medicine, Division of Pulmonary Medicine
Source
http://emedicine.com
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