Peribiliary cysts masquerading as choledocholithiasis

eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3NDVhNDg4ZDUxOWJlZmM0NmMyNmVjYTczOTkzYzExNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3OTQ3NTA2fQ.jGTXetL8VQpJMoSoKyEyyWsumKFL-UVs9swfqIDAy-2x1_wWQJQ6aRcpkITK-MYy3XruIWIRtsiHtvs8LxZOVl2bPEo0hFIkHhcxYs4xukEtMQabqLOp4XItPj-qM_lhEAJczpiae7q3SJU1tP-XGBLRkLjCe3A5m_3MVlPL2OW1WJ-dtRGz93JfrCTDj9Iz9pIX3zxVyIpgkB3GHZbw-SlhlrNH_E9BSyCVr-fajlKcTzSl1hm1Uwo7Kc040s3-V5cK4342g_nBzLorzrqw4m02R3M4mD2sxPbBNp3E132jQv6Hn7P-DjufTSggMTwl3rWEIpmzn_9z72giM0CI0w(mp4, (80.79 MB) Download video The major papilla was cannulated with a sphincterotome over straight wire. polypoid saccular structures were identified by cholangioscopy. A 70-year-old man presented to his primary care physician progressive shortness of breath. subsequent workup revealed normal chest radiograph, but the CT scan heterogeneous hepatic cysts. Cross-sectional abdominal imaging “beaded” bilobar intrahepatic biliary ductal dilation and narrowing distal common bile duct concerning for obstruction (Fig. 1). Laboratory analysis showed liver function tests. He reported 15 years heavy alcohol use. denied other risk factors chronic disease, fevers, chills, or night sweats. His physical examination unremarkable. referred gastroenterology department underwent an endoscopic ultrasound showing multiple anechoic in both lobes, extrahepatic tree, pancreatic head suspicious type IV choledochal cyst side-branch intraductal papillary neoplasms head. surgery offered Whipple pancreaticoduodenectomy remove all cystic portions tree lifelong surveillance ducts. Seeking second opinion, patient our institution where ERCP performed. demonstrated filling defects mid proximal chain-like appearance left main on cholangiogram suggestive stones 2). Balloon sweeps did not retrieve any debris. Cholangioscopy representing peribiliary cysts 3; Video 1, available online at www.videogie.org).Figure 3Cholangioscopy revealing dilated overlying mucosa.View Large Image Figure ViewerDownload Hi-res image (PPT) clinical history findings reviewed multidisciplinary team. Surveillance recommended MRI 6 months, which no change interval follow-up 4). remains asymptomatic undergoes yearly MRI. This unusual case presents diagnosis cysts, may be mistaken malignancy leading unnecessary interventions.1Lim J. Nissen N.N. McPhaul C. Annamalai A. et al.Peribiliary presenting as hilar cholangiocarcinoma end-stage disease.J Surg Case Rep. 2016; 2016: rjw130Crossref Google Scholar recent systematic review few cases described 3 types cysts: 1 (87%), isolated intrahepatic; 2 (7%), extrahepatic; (6%), 5).2Bazerbachi F. Haffar S. Sugihara T. proposal classification framework.BMJ Open Gastroenterol. 2018; 5e000204Crossref Scopus (23) had distribution, is often grouped most commonly men cirrhosis portal hypertension. Although two-thirds have been Japan, can occur from underlying disease abuse (like this patient) likely predisposing factor. Asymptomatic presentation, case, occurs 30%.2Bazerbachi For those symptoms, these are related (52%) (19%).2Bazerbachi Hepatobiliary malignancies noted 17% patients (most commonly, hepatocellular carcinoma), exclusively circumstances cysts.2Bazerbachi Autopsy reports note that 10% will epithelial changes glands; however, it unclear whether associated malignant degeneration.3Sato Y. Harada K. Sasaki M. al.Cystic micropapillary glands might represent precursor lesion neoplasms.Virchows Arch. 2014; 464: 157-163Crossref PubMed diagnostic 48% 64%, respectively, cholangioscopy necessary characterize access foci biopsy clench diagnosis.2Bazerbachi As opposed intermittent outpouchings along tree. Once excluded, best treatment address condition resulted formation. In intra- included cessation. symptomatic (extrahepatic) surgical resection considered. absence features, should considered given association between formation malignancy. Often, arises rather than degeneration; thus, carcinoma necessary. authors disclose financial relationships. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3NDVhNDg4ZDUxOWJlZmM0NmMyNmVjYTczOTkzYzExNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3OTQ3NTA2fQ.jGTXetL8VQpJMoSoKyEyyWsumKFL-UVs9swfqIDAy-2x1_wWQJQ6aRcpkITK-MYy3XruIWIRtsiHtvs8LxZOVl2bPEo0hFIkHhcxYs4xukEtMQabqLOp4XItPj-qM_lhEAJczpiae7q3SJU1tP-XGBLRkLjCe3A5m_3MVlPL2OW1WJ-dtRGz93JfrCTDj9Iz9pIX3zxVyIpgkB3GHZbw-SlhlrNH_E9BSyCVr-fajlKcTzSl1hm1Uwo7Kc040s3-V5cK4342g_nBzLorzrqw4m02R3M4mD2sxPbBNp3E132jQv6Hn7P-DjufTSggMTwl3rWEIpmzn_9z72giM0CI0w .mp4 Help files 1The