Cystic Disorders of the Bile Duct

Question 1

Type I bile duct cysts

Answer 1

Extrahepatic cystic (A), focal (B), or fusiform (C) dilation of the biliary tree

Question 2

Type II bile duct cysts

Answer 2

Extrahepatic supraduodenal saccular diverticulum of the CBD

Question 3

Type III bile duct cysts

Answer 3

Dilation of the intraduodenal CBD; aka choledochocele

Question 4

Type IV bile duct cysts

Answer 4

Dilation of both intrahepatic and extrahepatic bile ducts (A) or multiple extrahepatic dilations (B)

Question 5

Type V bile duct cysts

Answer 5

Intrahepatic ductal dilation; aka Caroli’s disease

Question 6

Tx of type I bile duct cysts

Answer 6

Cholecystectomy + kocherization of the duodenum + ligation of CBD distal to the cyst, w/ cephalad retraction of dilated duct to the hepatic duct confluence, frozen section of margins, 60 cm Roux-en-Y for end-to-side hepaticojejunostomy w/ single layer absorbables

Question 7

Tx of type II bile duct cysts

Answer 7

Complete excision of the cyst w/ resection & Roux-en-Y reconstruction or excision w/ primary closure over a T tube

Question 8

Tx of type III bile duct cysts

Answer 8

Complete excision via lateral duodenostomy after kocherization w/ CBD and pancreatic duct identification; sphincteroplasty w/ sewing of duct to duodenal mucosa w/ interrupted absorbables. ERCP w/ sphincterotomy for those unable to tolerate surgery. Whipple if malignancy suspected.

Question 9

Tx of type IV bile duct cysts

Answer 9

Complete extrahepatic cyst excision w/ hepaticojejunostomy. Hepatectomy if only one lobe of liver involved.

Question 10

Tx of type V bile duct cysts

Answer 10

Tx infectious complications w/ drainage, stone extraction, abx, ursodiol. Hepatectomy if only one lobe involved. Possible liver transplant for severe portal htn or failed drainage procedure.