Ruptured choledochal cyst: a rare presentation and unique approach to management

We present the rare case of a ruptured choledochal cyst (CC) in a young woman presenting with a two-day history of worsening upper abdominal pain. Imaging revealed a contracted gallbladder, dilated common bile duct (CBD), and a large amount of peritoneal fluid. Percutaneous paracentesis was performed, obtaining bilious fluid. Further imaging revealed cystic dilatation of the CBD and the diagnosis of rupture CC type I was made. The patient was initially managed conservatively with percutaneous drains, IV antibiotic therapy, and sphincterotomy through an ERCP. Elective cyst resection and Roux-en-Y hepatojejunostomy was performed 8 weeks later. It is important to differentiate a ruptured CC from other surgical emergencies without exploratory laparotomy. Initial conservative management could be considered, followed by elective resection once inflammation, infection, and other complications have resolved, avoiding the increased risk associated with an emergency operation or two-stage laparotomy.