Hepatic WILLIAM

Choledochal

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are

and

associated

jaundice

and

lowing

L. SCHEY,’

cysts

often

was

other

duct

the

due

of the correct

the

tree

of the

radiographic preoperative

The

folof

which

he

and

fatigue

intensified.

a

He

depressed

was reported gastrointestinal

irregularities

in

stomach

was

ally

slightly

and

initially

and

aching

had

abdominal

experienced

the

count

esophagus but

which

no

jaundice.

cystic

“nonvisualization

1B)

citrate

the

patient’s

Oral

arteries, artery. return.

formation.

was

hepatic

Received

Am

1

Department

2

Division

3

Department

duct

April

29.

2)

the

1976,

The

of Nuclear

J Roentgenol

Medicine,

of Radiology.

128:318-320,

mass

accepted

of Radiology.

minimal

accounting right

for

lobe

cirrhosis.

neck amputated

right

celiac

lobe

patient

was

of

mass

did

choledochal Radiographically,

cyst,

of

The

the mass

and oversewn.

1D) and

Reese

Memorial

February

Medical

Hospital.

1977

20.

Center.

29th

were

Street

Harvey.

Illinois

rather

also

the

represent

a

are generally radiographic

simulating

consistent

the

below

those

was never a displaced with

of

jaundiced. gallbladder

a choledochal

may

have

a mass would be reported during

been

real

and

hypersplenism. alkaline phosphatase [4].

However,

and hepatic scanning similar to those of the

was

with 9Tc

fail

6].

so

[5,

Both

choledochal

on

and

60426.

318

citrate colloid

yielded study.

correct

rose have

intravenous

bengal liver been reported

diagnosis

was

of

location

phosphatase other

Avenue. 60616

Chicago.

in-

likely to demonstrate or neoplasia, it may

however,

alkaline

Ellis

67Ga sulphur

bile that hepatic

because

Illinois

of

occasion;

The

tree

evidence

so packed with inspissated drained by the obstructed

primarily

biliary

no

A continuous-drip

cystogram and/or proved helpful [7). cysts

effect

nonneoplastic “cystic” impression or mass was suggested by both examin67Ga citrate is more in areas of infection

to do

extremely the initial

a transient

suggested

there

the value,

possibilities

1976 Chicago.

duct

these or

symptoms

structures by such The thrombocytopenia

Numerous

Center,

bile

but surgical

duct

maldevelopment shunt from

may

but the patient the findings of

duodenum

rare. We or any in

hepatic

common

cirrhotic. This probably indicates that have been of value in this patient.

undersurface

August

Medical

the

diverticulum

create

extremely jaundice

anatomic developed

ations. Although increased activity

was liver

transferred

the

from

to the

The

A noninflammatory intrahepatic cystic

was

of the

in the

revision

Reese

Michael

Ingalls

[2).

The

fection, findings

and stretching of the Late films in the series

indented

after

Michael

findings

hospitalization

A celiac

filling

tree are without

arose

duct

1.

[1

of secondary Elevated

medi-

gallbladder’

a defect

requirements,

(fig.

hepatic

venous unusual.

to Michael Reese Medical Center. The information transferred with the patient was reviewed and substantiated. At surgery. a cystic mass measuring approximately 6-8 cm in diameter was found arising from a short neck off the right

diverticulum

duct

(fig.

The

displaced

cholecystogram

satisfactory

demonstrated

blood

vein, The

cyst, although visualization of the gallbladder is not unusual [31. The presence of varices decreases the likelihood of a classic choledochal cyst since impression of portal

serpiginous

varix bulb

of the

demonstrated

scan

portal

suggesting

form of gallbladder duplication, asymptomatic, coincidental

the liver (medially) and a 99#{176}Tc sulphur colloid study (fig. 1C) demonstrated a finding similar to the gallium study. with slightly better definition. An intrahepatic mass was suspected and the patient was prepared for surgery. Because of difficulties in meeting

nodular

the enlargement.

the common bile duct. This represent an incompletely

proximal

Bone

demonstrated

1A).

artery. elevation of the hepatic hepatic branches and the cystic did not clearly define the venous A 67Ga

splenic

of the biliary case presenting

involvement

duodenal

(fig.

the

than may

pain

(83.000/mm3).

suggesting

the

anteriorly

as

(fig.

platelet

as normal. examination

normal,

reported

angiogram

compressed

and

S. DRAGOMER3

and thediverticular did well postoperatively.

Diverticula know of no

Report

diarrhea, or vomiting but felt that he was becoming weaker. He had been hit with a baseball in the abdomen approximately 1 year prior to admission. It was not a direct blow nor did he have to quit the game. The impact was lateral to the site of subsequent abdominal pain. There was no pertinent family history nor travel out of his suburban Chicago environment. Th patient was admitted to Ingalls Memorial Hospital for evaluation and treatment. Physical examination demonstrated hepatomegaly 5-6 cm below the right costal margin, and splenomegaly 3 cm below the left costal margin. A palpable mass was suspected below the enlarged lobes of the liver in the right midclavicular line. Its transverse diameter was approximately 4 cm; it was firm and questionably nodular. There was no bruit heard over the mass. and no cutaneous hemangiomata were noted during close investigation. Laboratory investigation was normal except for an abnormal alkaline phosphatase (123 Bodansky marrow Upper

ANDREI

also

slightly

Cyst

Discussion

developed

gradually

units)

was

wasextirpated The patient

A 12-year-old white male was admitted to Michael Reese Medical Center with the diagnosis of a right upper quadrant mass. He had been in good health until 3 weeks prior to examinwhen

and

formation

liver

and isotope diagnosis

AND

diverticulum.

Case

ation

liver

varix

absence

a Choledochal

S. LIPSCHUTZ,3

including

cause.

to

HAROLD

biliary

complex of

enigmatic

Simulating

PINSKY,2

of the

clinical

suggestive

initially

M.

anomalies a

classic findings, but analysis scan studies permitted the of hepatic

Diverticulum

STEVEN

with

a history

case

Duct

Illinois

60616

the

the

and

the

were

diverticulum

the portion duct was studies

suggested of the

chole-

scan might have to demonstrate of the already

would

not

preoperatively “mass’

absence considered,

the of

high

jaundice. including

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CASE

Fig

1 -A.

8 Celiac ina:cating of decreased

activity

(arrows).

benign and alies (e.g., intrahepatic

Upper

gastrointestinal

angiogram showing cystic mass Note initially

examination

showing

displacement of right absence of neovascularity

in anterior

portion

of

right

extrinsic

hepatic artery C. Anterior hepatic

lobe

319

REPORTS

compression

on

duodenal

and its peripheral branches view 30 mm after inlection Splenomegaly

also

demonstrated

malignant hepatic gastrointestinal

neoplasia, congenital or mesenteric cysts).

anomand

3

Babbit

DP,

concept

of

4. Kaplan

hematoma.

5. Silberstein

REFERENCES

SW.

Philadelphia,

2. Goor

DA,

104:306.

Skandalakis Saunders,

Ebert 1972

‘

and

first

portion

D,

of

(most

cystic artery Tc sulphur

colloid

Laterally

duodenum

medial

arrow).

showing

displaced

area

gallbladder

overlooked

Starshak

JE:

Embryology

for

6. Harvey

Surgeons.

secutive

1972

PA: Anomalies

of the biliary

7. Rosenfield tree

Arch

Surg

graphic

RJ, Am

etiology.

MM’

200-202.

1. Gray

bulb and of

Alkaline

Clemett

AR:

Choledochal

J Roentgenol

1 19:57-62.

phosphatase.

N EnglJ

cyst: 1973 Med

286:

1974 EB

WC.

Cancerdiagnosis.AmJMed6O:226-237,

Podoloff

infection

N, techniques

DA,

searches.

Griscom

NT: Radiology

Knopp

Gallium-67 Med 1 1 :2-4,

J Nucl Choledochal 114

1976

DT:

1 13-1

cysts: 19.

1975

in 68 con1975 roentgeno-

a

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320

CASE

O

1._,,_,__,

WI. NEPATIC PtJCT

(TNE

0

Fiq 2 emphasizing relationships

A. Diverticulum abrl(irmal

MASS)

as vistiali,’iii str

ict

ir

i

and

at surgury its origin

B. Schematic rat her t han

diagram size

t rue

REPORTS