Ruptured choledochal cyst: a rare presentation and unique approach to management

Biliary cysts (BC) are congenital cystic dilatations of the intra- and/or extra-hepatic biliary tree that are exceedingly rare in North America. Incidence is geographically dependent, being more common in Asia (1/1,000) than in western countries (1/100,000-150,000). Women are more commonly affected than men in a 3-4:1 ratio (1). Traditionally, lesions affecting only the common bile duct (CBD) are referred to specifically as choledochal cysts (CC). In 1969, Babbitt established that the most probable cause of BC relies on an anomalous pancreatobiliary junction (APBJ) (2). According to Yotuyangi, an anomalous proliferation of the biliary epithelial cells before bile duct cannulation during development is one possible explanation (3). The most well-known classification system for BCs was established by Todani (4). There are five types, type I being the most common. Types I, II, III, and IVb are extra-hepatic and type IVa and V are intra-hepatic. BCs have the ability to produce a wide spectrum of complications, including strictures, cholangitis, rupture with biliary peritonitis, and malignancy (5). In this paper, we present the rare case of a ruptured CC managed conservatively at first, followed by elective resection after resolution of biliary peritonitis