Lithiasic, congenital, choledochal dilatation: problems of diagnosis and therapy

We report a case of a 30-year old female with congenital lithiasic choledochal dilatation which was not diagnosed at the ultrasonographic examination. Congenital biliary dilatation abnormalities are rare and may clinically present with episodic biliary colics or more rarely with recurrent pancreatis. Ultrasound, CT-scanning and ERCP usually make these anatomic alterations evident but in some cases there may be some doubt despite the vast range of radiological techniques available (PTC, Tc99m-Isida scinti-scan). The best results from a diagnostic point of view are obtained from the ERCP that may in fact visualize an anomalous pancreatico-biliary junction, rule out carcinoma, accurately define the cyst dimensions or show the intrahepatic ductal radicals. Furthermore, the extraction of intracystic stones or the treatment of choledochocele through a papillostomy may be performed. However the ERCP may cause traumatic pancreatitis, above all in youngster as was verified in our patient. During surgical exploration, the definitive diagnosis can be achieved via intraoperative cholangiography. We emphasize that in patients with congenital choledochal dilatation, the dilated choledochus should be excised even in young children to avoid the risk of malignancy which may occur also following cyso-duodeno- or cystojejunostomy treatment. In our patient an hepatiocojejunostomy on a Roux-en-Y limb was performed. This single case has been oresented along with a review of the literature to recall such anomalies in differential diagnosis of biliary colics and to stress that the choice treatment is surgical resection.