Management of an unusual case of lower gastro-intestinal bleeding: ulcerated choledochocele

E Ray-Offor, MBBS, FWACS, DMAS, S N Elenwo, MBBS, FWACS, P O Igwe, MBBS. University of Port-Harcourt Teaching Hospital Port-Harcourt Rivers State Nigeria.

Background: Choledochal cyst is an uncommon condition of the extrabiliary tract with or without involvement of the intrahepatic biliary duct. The dilation of the distal extrabiliary tract in the region of the ampulla of Vater forms a choledochocele. Massive bleeding gastro-intestinal haemorrhage from a choledochal cyst presenting as haematochezia is rare.

Case report: A 13 year-old obese boy with sudden onset of passage of bright red blood with a fainting episode of one day duration. There was no anal protrusion, jaundice, recurrent upper abdominal pain nor bleeding from any other orifice. An emergency OGD showed profuse bleeding in the region of a sub-mucosal mass in the medial aspect of the 2nd part of the duodenum narrowing the lumen (Fig1 &2). An emergency exploratory laparotomy revealed a cystic mass in the second part of the duodenum containing bilious fluid with ulcerated mucosa at the dome. The cyst was excised and marsupialized. Post-operative recovery was complicated by adhesive small bowel obstruction on the 9th day post operation (DPO) after discharge on 7DPO. Laparoscopy was done which revealed multiple adhesions of small bowel and omentum to the posterior aspect of the anterior abdominal wall along the midline laparotomy incision. Laparoscopic adhesiolysis was successfully performed (Fig 3, 4). He was discharged home in good clinical state on the 3rd day post laparoscopic surgery.

Conclusion: The management of massive bleeding per rectum involves an oesophagogastroduodenoscopy. Sequel to an endoscopic impression a prompt surgical intervention is indicated for haemorrhage from a choledochal cyst. Key words: Choledochal cyst, Haemorrhage.

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