A 63-year-old woman with no medical or surgical history came to the outpatient clinic
presenting with 6 months of unquantified unintentional weight loss and jaundice. Physical
examination documented only jaundice with no other alterations.
Laboratory results documented an obstructive biliary pattern ([Table 1]). Magnetic resonance imaging (MRI) showed no evidence of neoplasia and a dilatation
of the choledochus and intraductal image ([Fig. 1]). Echo-endoscopy showed only an image suggestive of a 2-mm stone in the choledochus
([Fig. 2]). Endoscopic retrograde cholangiopancreatography and cholangioscopy was then performed
using direct visualization by SpyGlass (Boston Scientific, Marlborough, Massachusetts,
USA) in which multiple subepithelial, rounded and translucent lesions corresponding
to cysts were observed, some of which ruptured spontaneously during the procedure
([Fig. 3], [Video 1]). Jaundice resolved after the procedure. Biopsies of the lesions were taken by SpyBite
(Boston Scientific) without finding neoplastic pathology. After 6 months of observation,
the patient is asymptomatic and continues to be followed up.
Table 1 Laboratory results
|
Laboratory
|
28/02/23
|
Reference values
|
|
Leukocytes (×10^3)
|
6220
|
4.5–11.3
|
|
Hemoglobin (g/dL)
|
14.8
|
12.3–15.3
|
|
Platelets (×10^3)
|
188000
|
150–450
|
|
Alkaline phosphatase (U/L)
|
710
|
35–104
|
|
Gamma glutamyl transferase (U/L)
|
774
|
6–42
|
|
Alanine amino transferase (ALT) (U/L)
|
89
|
0–31
|
|
Aspartate amino transferase (AST) (U/L)
|
86
|
0–32
|
|
Total bilirubin (mg/dL)
|
2.55
|
0–1
|
|
Direct bilirubin (conjugated) (mg/dL)
|
2.1
|
0–0.3
|
|
Creatinine (mg/dL)
|
0.83
|
0.51–0.95
|
|
INR
|
0.85
|
–
|
|
CA 19–9
|
52
|
0–39
|
|
ACE
|
2.5
|
0–4.3
|
Fig. 1 Dilatation of the choledochus with an image that could correspond to calculus (only
visualized in a sequence). However, there is an abrupt termination of the choledochus
and saccular dilatations of the intrahepatic biliary tract, so it is not possible
to rule out periampullary lesions. Endoscopic evaluation is suggested. The small cystic
lesion of the body of the pancreatic head could correspond to intraductal papillary
mucinous intraductal neoplasm with no ominous signs. Cysts are simple hepatic cysts.
Fig. 2 Pancreatic head cyst measuring 6×9 mm, without communication with the main or secondary
pancreatic duct. 7 mm choledochus with micro calculus of 2 mm inside. Papilla are
endoscopically and endosonographically normal.
Fig. 3 Cholangiopancreatography: Multiple filling defects at the level of the middle choledochus, proximal choledochus,
right and left hepatic duct, with dilated intra- and extra-hepatic biliary tract.
Cholangioscopy: Multiple subepithelial, rounded, translucent lesions corresponding to cysts, some
of which rupture spontaneously. At the level of the left hepatic duct, there is a
cyst that generates partial occlusion of two ducts that is broken by SpyBite forceps.
Endoscopic retrograde cholangiopancreatography and cholangioscopy was performed using
direct visualization. Multiple subepithelial, rounded, and translucent lesions were
observed corresponding to cysts, some of which ruptured spontaneously during the procedure.Video
1
Peribiliary cysts [1] are saccular structures formed from the dilatation of peribiliary glands. They are
usually tiny (<10 mm) and do not communicate with the bile ducts [2]. They are mainly associated with cirrhosis and enolism (38%). They are more prevalent
in the male sex (80%), with less female representation. Regarding clinical manifestations,
obstructive and constitutional biliary syndrome with consequent suspicion of neoplastic
obstruction of the biliary tract is the reason for consultation and clinical approach
in 19% of patients [3]
. With respect to detection, although computed tomography (CT) and MRI can document
typical cystic lesions and thus be diagnostic in up to 48% and 64% of cases, respectively,
in some scenarios cholangioscopy may be required to characterize and biopsy in order
to clarify the diagnosis [4]
. Regarding treatment, the authors agree that asymptomatic patients do not require specific
management or follow-up. In our case, cholangioscopy was indicated due to obstructive
biliary involvement, with subsequent resolution of symptoms.
Endoscopy_UCTN_Code_TTT_1AQ_2AK
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