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Special Feature
Oct 2011

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Third Department of Surgery, University of Athens School of Medicine, Attikon University Hospital, Athens, Greece.

Arch Surg. 2011;146(10):1213. doi:10.1001/archsurg.2011.263-a

A 27-year-old woman was admitted on an emergency basis, with acute pain in the right upper abdominal quadrant and nausea and vomiting for the previous 3 days. Her medical history was normal. On physical examination, she was dehydrated, with a positive Murphy sign and mild fever. Blood cell count was normal. Results of blood chemistry demonstrated a mild hyperbilirubinemia (total bilirubin level: 1.8 mg/dL and direct bilirubin level: 1.6 mg/dL [to convert both to micromoles per liter, multiply by 17.104]) and mildly elevated alkaline phosphatase (150 U/L [to convert to microkatals per liter, multiply by 0.0167]) and γ-glutaminotranspeptidase (105 U/L) levels.

The abdominal ultrasonography revealed cholelithiasis and a cystic mass in contact with the second portion of the duodenum containing stones. The distal common bile duct was dilated, with a maximum diameter of 1.4 cm. Endoscopy revealed a smooth, round mass protruding into the lumen and obstructing the second portion of the duodenum. Computed tomographic scan of the abdomen showed cholelithiasis and a cystic mass containing stones, obstructing the second portion of the duodenum, and causing distention of the stomach and the proximal duodenum (Figure 1).

Image not available

Figure 1. Abdominal computed tomographic scan showing cholelithiasis and a cystic mass adjacent to the second portion of the duodenum containing stones.

The patient underwent surgical exploration. Through a right subcostal incision, the gallbladder was first removed. Then the dilated duodenum was mobilized and was opened transversely at the second portion. A juxtapapillary 3 × 4-cm cystic mass, with an inflamed thick wall, containing palpable stones and obstructing the duodenal lumen, was revealed (Figure 2). Transduodenal resection of the cyst and sphincteroplasty were performed.

Image not available

Figure 2. After opening the distended duodenal wall, a 3 × 4-cm cystic mass was revealed emerging from the papilla of Vater and protruding into the duodenal lumen.

What Is the Diagnosis?

A.  Choledocholithiasis with stone impaction

B.  Duodenal diverticulum

C.  Choledochocele

D.  Duodenal duplication cyst