Ruptured choledochal cyst: recognition and management

A case is described of the rupture of a choledochal cyst in a 21-year-old man involved in a motor vehicle accident. At laparotomy, a haemoperitoneum was traced to a large haematoma in the lesser omentum which extended into the mesocolon and was found to be tinged with bile. Eventually it became apparent that the primary pathological condition was a large choledochal cyst into which opened the gallbladder. This cyst had split longitudinally down its anterior surface from the porta hepatis to the duodenum. Bile leakage was controlled by inserting a Foley catheter into the common hepatic duct, and inflating the balloon. Postoperative cholangiography showed massive cystic dilation of the intrahepatic ducts. Five days after the initial operation, a Roux-en Y cystjejunostomy was performed, and the patient has been well since. Crucial points in the emergency management of this condition appear to be in its recognition, and the provision of an adequate method of primary biliary drainage, if the condition of the patient demands staged management. End-to-end cystjejunostomy provides a satisfactory method of final drainage.