An 81-year-old male patient was admitted in February 2008 due to painless jaundice, anorexia and a two-week history of general malaise.
The patient had a history of progressive cognitive impairment, diabetes mellitus, hypertension, chronic atrial fibrillation, chronic obstructive pulmonary disease, abdominal aortic aneurysm and had a biological mitral prosthesis.
Physical examination revealed a poor general condition with obtundation and disorientation, fever of 38.5 oC, mucocutaneous jaundice and a palpabletended gallbladder.
The hemogram showed moderate leukocytosis with left shift.
In the general biochemistry, total bilirubin was high (22.5 g/dl) with direct predominance (15.6 g/dl).
Other enzymes of colostasis and cytolysis alkaline phosphatase (AP) 287 U/l (normal < 129), GGT 472 U/l, GOT 134 U/l and GPT 227 U/l were also increased.
Abdominal ultrasound showed a distended gallbladder with multiple stones and dilatation of intrahepatic and extrahepatic bile ducts.
Computed tomography (CT) described a 3 cm mass in the pancreatic head that had the common bile duct and pancreatic duct.
The intrahepatic bile duct was consistent with the hydropic gallbladder.
The diagnosis of pancreatic neoplasia with biliary obstruction was made.
There were no references to a possible choledochal cyst
Endoscopic retrograde cholangiography (ERCP) showed a saccular formation of about 3 cm in diameter, soft and depressible to contact with the sphincter in the second portion of the duodenum.
The papillary orifice was identified at its right upper edge.
After cannulation, contrast injection simultaneously opacified the cyst, bile duct (BV) and Wirsung.
The pancreatic duct appeared amputated at the junction of the head and body.
At the same time as the pancreatic lesion, the middle common bile duct showed marked and irregular stenosis.
The image taken together could be considered as typical of a pancreatic neoplasm with choledochal obstruction associated with a common bile duct cystocele.
A sphincterotomy was performed and an 8 cm self-expanding stent was placed in the duodenum.
The patient progressed rapidly with disappearance of fever, improvement in general condition and remission of jaundice.
Obviously, surgical treatment is discouraged.
In the review 3 performed, the patient's condition was acceptable, did not report digestive discomfort and total bilirubin was 1.5 g/dl, with normal transaminases 172 U/ FA 184GT U/l, and G.
Nine months later she is still alive and has not required replacement of the prosthesis.
