A Case of Choledochal Cyst Type IVa Complicated by Multiple Choledocholithiasis and Recurrent Cholangitis: Therapeutic Endoscopic Retrograde Cholangiopancreatography and Endoscopic Nasobiliary Drainage

ABSTRACT

A 5-year-old male patient was admitted due to fever, and right upper abdominal pain for 2 weeks. He showed severe right upper quadrant tenderness on palpation, hepatomegaly 5 cm below the right costal margin, no mass, and no splenomegaly. On biochemical studies, ALT was 380IU/ml, AST 462IU/ml, alkaline phosphatase 1,069IU/ml, GTP 239IU/ml, and total bilirubin 2.1mg/dl. Endoscopic retrograde cholangiopancreatography (ERCP) showed cylindrical dilatations of CBD and cystic dilatations with strictures of extrahepatic and both bilateral intrahepatic bile ducts (choledochal cyst type IVa) with multiple stones in the CBD and extra- and intrahepatic bile ducts. Endoscopic sphincterotomy (EST) and stone extraction with basket and balloon were performed successfully. The bile was severely purulent and the stones were pigment stones. Klebsiella pneumoniae were dominantly grown on bile culture. An endoscopic nasobiliary drainage (ENBD) tube was inserted to treat biliary sepsis. The bile ducts were irrigated with tobramycin-mixed normal saline twice a day for 2 week, when ALT, AST, total bilirubin and liver size were normalized and no more bacteria was grown on bile culture. The clinical symptoms were improved just after the therapeutic ERCP. There was no side effect by ERCP, EST and ENBD.