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All right, next five year old female with history of autism,

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asthma presented with abdominal pain and vomiting. And uh,

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we did ultrasound. The,

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the lipase was slightly elevated so they were thinking about pancreatitis and

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the liver function tests were normal.

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So I'm going to show you ultrasound.

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These are the ultrasound images

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where you can scroll and see the normal, uh, liver parenchyma.

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As we come to the center near the pole, you see dilated bile ducts.

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We confirmed on doppler that these are not the venous system.

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Alright,

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So dilated, uh, dilated biliary system,

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ex extra as well as intra hepatic biliary ductal dilatation

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involving both the lobes. That's a gallbladder.

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Gallbladder. Looks like there is some hyper coic stuff,

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inated contents within the gallbladder.

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The gallbladder wall is slightly thick.

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There is no lytic collection. Murphy's sign was negative.

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So

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As I said earlier on colored Doppler examination,

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there was no abnormal vascularity. That's the left kidney,

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that's the spleen. The spleen is not enlarged.

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So here you are dealing with dilated bili ducts,

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very small contracted gallbladder with inspi contents.

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And the patient had elevated lipase because we could not see the pancreatic head

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very well or we could not evaluate pancreas very well. Uh,

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we were asked to do M R C P.

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I'm going to show you some T2 weighted images, heavily ED images.

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You can see the common bile duct tapers very well.

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That's the pancreatic duct, which is normal and has a normal insertion.

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That's the common bile duct, which is dilated.

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This is the extrahepatic common bile duct. As we scroll,

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there is dilation of the intra hepatic bile ducts involving both the lobes

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that's the left side,

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so severe dilation of the intra hepatic bile ducts,

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as well as the extrahepatic common bile duct, normal pancreatic duct.

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And that's the gallad with the stone.

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I'm going to show one more AAL to confirm.

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What we are seeing is right. None of these are enhancing.

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This is the poston contrast examination.

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You can see there are no focal enhancing lesions in the liver.

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The bile ducts are dilated,

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both the right as well as left low ducts are dilated.

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And that's the common bile duct.

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That's the extra hepatic portion of the common bile duct.

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That's a pancreatic head. And you can see the pancreatic duct,

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the confluence of the common bi duct and the pancreatic duct here.

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And the pancreatic duct is absolutely normal.

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There is no abnormal enhancement of the pancreas.

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There is no pseudo pancreatic cy or per pancreatic inflammation that was

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confirmed on ti weighted images that there was no per pancreatic fluid or

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any inflammation.

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So essentially we are dealing with dilated biliary system in this patient who

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presented with some abdominal pain and elevated lipase.

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Now, uh, can we bring up the poll question?

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What is the most likely diagnosis pancreatic cancer spin co cyst or

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sclerosis? Cholangitis

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Colloidal cyst is the correct answer because we have dilated

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intra and extrahepatic biliary ducts.

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So what happens is in the embryologic age

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there is abnormal confluence.

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There is mild tilt in the insertion of the pancreatic duct,

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which is very difficult to actually find on the imaging.

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That leads to the reflux of the pancreatic juice into the distal

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common bile duct, which results in the dilation of the common bile duct.

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That's why the type one is the most common type of the, um,

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co cyst.

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Danny's classification is the classic classification everyone follows. Uh,

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so type four A is associated with both intra and extra hepatic

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ductal dilatation and is seen in approximately 30% of the patients who have

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political cysts.

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M R C P is the gold standard to evaluate the dilated bile ducts

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because this could be secondary to the structure in the distal common bile duct.

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A tiny stone in the distal, a common bile duct, which could be,

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which is usually political ets and which can also lead to pancreatitis.

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So this patient presented with elevated, uh,

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lipase and there was suspicion of, uh, pancreatitis.

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They can rarely present with jaundice. Um,

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and as our patient presented with pain,

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that is another finding our patient actually had vomiting as well.

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If the system is infected,

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they can also present with fever and ascending cholangitis. Like picture.

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The most common complication,

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known complication of co cyst is cholangiocarcinoma.

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Cholangiocarcinomas usually happen in second or third decades of life. Um,

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although in pediatrics we don't see that complication. However,

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we are extremely concerned and we have to diagnose co cyst any

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type, um, earlier than later. What are the options?

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Surgery is is better because there is zero risk of colonic carcinoma.

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Spnc troma if the system is dilated and is infected.

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Stent can also be an option.

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Excision of the extra hepatic part of the cyst and drainage of the intra hepatic

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potion, especially with type four A is another option of, uh,

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of uh, treatment. So let me show you what we did with this patient.

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We actually did stenting. As you can see,

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this is the endoscope which came in and this is the, uh,

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this is the wire guide wire in the common bile duct.

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And ultimately this patient got a stent and this was confirmed that this

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is improperly properly positioned by putting the contrast in the bile duct.

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So this patient is doing fine now. Uh,

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but it was a very hard diagnosis just because it was difficult to figure out

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whether there was distal common bi duct stricture,

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a tiny stone because the gallbladder was also not, uh, normal in this patient

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as well. Well as bi different types of bilis, they can,

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they can look alike.

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Bilis usually present early on within four weeks of life. And,

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uh,

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co cyst are usually incidentally found in later part of the life antenatally

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if they, these co cys are extremely huge.

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They can be diagnosed anally and, um,

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all the newborn babies who are diagnosed with co potential co cyst,

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uh, they get M R C P in the newborn period.