A 6-year-old boy is brought to the office for an annual wellness check. He has no symptoms. Medical and family history are unremarkable. Vital signs are within normal limits. The patient's height and weight are both appropriate for age. On examination, an abdominal mass is palpated in the right upper quadrant. Laboratory evaluation, including bilirubin, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase, is unremarkable. A common bile duct cyst is identified by abdominal ultrasound and is confirmed by MR cholangiopancreatography. Which of the following is the best next step in management?

Question

A 6-year-old boy is brought to the office for an annual wellness check.  He has no symptoms.  Medical and family history are unremarkable.  Vital signs are within normal limits.  The patient's height and weight are both appropriate for age.  On examination, an abdominal mass is palpated in the right upper quadrant.  Laboratory evaluation, including bilirubin, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase, is unremarkable.  A common bile duct cyst is identified by abdominal ultrasound and is confirmed by MR cholangiopancreatography.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d618_8269_bc81_c9d1f14b4237_MD0003_00 This patient has a biliary cyst, or a cystic dilation of the biliary tree that most commonly involves the common bile duct (type I). Most cysts are congenital and present in early childhood with right upper quadrant (RUQ) pain, RUQ mass, and/or jaundice. However, a minority of patients are asymptomatic, as seen here, and identified based on examination or imaging obtained for other reasons. Laboratory evaluation in asymptomatic patients is typically normal. type I Management of most uncomplicated biliary cysts is complete cyst resection at the time of diagnosis due to a dramatically increased malignancy risk (eg, cholangiocarcinoma, gallbladder cancer, pancreatic cancer) up to 30 times greater than unaffected patients (Choice B). Patients with obstructive complications (eg, cholangitis, pancreatitis) should be treated for the acute condition first, followed by surgical cyst resection. A roux-en-Y hepaticojejunostomy is usually performed at the time of cystectomy to create a conduit that facilitates the flow of bile. There is still a small risk for developing cancer in the remaining bile ducts after surgery, and serial laboratory testing with or without imaging is usually recommended postoperatively. (Choices A and C) Secondary biliary cirrhosis is a rare complication of untreated biliary cysts and is caused by prolonged obstruction with recurrent cholangitis, findings which are not present in this case. Although surgical resection does minimize complications associated with biliary cysts, the purpose of timely cyst resection is to decrease the risk for malignancy. Educational objective: Biliary cysts may be asymptomatic or present with abdominal pain, a right upper quadrant mass, and/or jaundice. All patients should undergo cyst resection to decrease the risk for malignancy (eg, cholangiocarcinoma, gallbladder cancer, pancreatic cancer). References: Pediatric choledochal cysts: diagnosis and current management. (http://www.ncbi.nlm.nih.gov/pubmed/28364277) Choledochal cysts: Presentation, clinical differentiation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/25442379)

A 6-Year-Old Boy Is Brought to the Office for an Annual