Gastrointest Radiol l, 305-314(1977) Gastrointestinal Radiology by Springer-Verlag 1977 Choledochal Cyst in Adults A Clinical and Radiological Study in Ten Cases* Gary G. Ghahremani, Chien-Tai Lu, Ray M. Woodlief, and Vincent P. Chuang Departments of Radiology, Virginia Commonwealth University-Medical College of Virginia Hospitals, Richmond, Virginia, USA and The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA Abstract. Choledochal cysts ar.e being recognized with an increasing frequency among the adult population. In this series a correct preoperative diagnosis was established in eight of the ten patients. The clinical triad of obstructive jaundice, right upper abdominal pain, and a palpable flactuant mass was noted in only two cases but at least one of these symptoms was present in all patients. Acute pancreatitis, chole- cystitis, and biliary calculi were the commonly asso- ciated findings. New etiologic and clinical concepts of choledochal cysts are reviewed and the spectrum of radiographic features in adults is presented. Key words: Biliary tract: abnormalities, cysts, dis- eases, obstruction - Cholangiography: infusion, iso- tope, operative - Choledochal cyst: arteriographic features, complications, diagnosis. Choledochal cyst is a localized aneurysmal dilatation of the extrahepatic bile ducts. The abnormality is usually manifested in children, and the combination of intermittent obstructive jaundice, right upper ab- dominal pain, and a palpable subcostal mass forms a diagnostic triad for this entity [1-5]. Although the greater majority of 700 reported cases have been in the pediatric age group, the recent literature indicates that a significant number of chole- dochal cysts either remain clinically silent until adult- hood or the lesion develops later in life [6 11]. Since most choledochal cysts in adults do not present with the classic symptom triad noted in children, the cor- * Presented at 77th Annual Meeting of the American Roentgen Ray Society, Washington, D.C., September 1976 Address reprint requests to." G.G. Ghahremani, M.D., Department of Radiology, Evanston Hospital-Northwestern University, Evan- ston, IL 60201, USA rect preoperative diagnosis will depend upon a high index of clinical suspicion and a careful radiologic evaluation of the patient [1, 2, 6~]. Therefore, it seems appropriate to: (a) report our experience with ten adults including eight in whom the correct diagnosis of a choledochal cyst was estab- lished preoperatively ; (b) review of the pertinent liter- ature on etiologic and clinical features of the entity; and (c) provide guidelines for effective utilization of radiologic modalities in the diagnosis of choledochal cysts. Material and Methods This series represents the collective experience of the authors at the hospitals of The University of Chicago and the Medical College of Virginia. There were eight female and two male patients. Two were Chinese women, one was a black female and the other seven were Caucasian. The age of the patients at the time of diagnosis ranged from 17 to 59 years. The clinical presentation was variable, with symptoms ranging from a few weeks to several years in duration. All patients had a history of intermittent and vague epigastric pain usually occurring after meals but only six of the ten cases had a palpable tender right upper abdominal mass on admission. One of these patients presented with all the features of the classic symptom triad that permitted a correct diagnosis to be suggested on clinical grounds. On the other hand choledochal cyst was a fully unsuspected finding in two patients with acute pancreatitis and in each of two instances of cholecystitis and biliary calculi. Radiologic visualization of the choledochal cyst was achieved by infusion cholangiography in five of the patients. In three other cases the correct preoperative diagnosis was established by a combi- nation ofarteriography, radionuclide scanning of the liver, percuta- neous transhepatic cholangiography, or cyst puncture as well as the findings on barium studies of the gastrointestinal tract. From our clinical material the following six case histories have been selected and are being presented to demonstrate the spectrum of the clinical and radio- logic findings of choledochal cyst.