Figure 1
Normal Anatomy
Figure shows the normal anatomy
Anatomical variations of the Cystic Duct
SectionAbdominal imaging
Case TypeAnatomy and Functional Imaging
AuthorsRamya Thiagarajah Khalid Khalifa
Connected authors
72 years, female
Clinical History
This case highlights the anatomy of the cystic duct and its anatomical variations. Careful identification of anatomical anomalies should help to reduce the incidence of bile duct injuries during
laparoscopic cholecystectomy.
Imaging Findings
A 72-year-old female came to hospital complaining of persistent pain in the right upper quadrant. Her blood tests revealed a raised ALP 156 and raised ALT 98. An ultrasound scan showed the
gallbladder was difficult to localize because it appeared contracted. However, there was suspicion that it was contracted and contained some small stones. The biliary tree was not dilated. The
patient underwent a laparoscopic cholecystectomy. An intra-operative cholangiogram highlighted the anomaly of a short cystic duct arising from the right hepatic bile duct. Two days post-operation,
the patient complained of right hypochondrium pain and despite normal liver function tests, her inflammatory markers were raised. A second ultrasound scan showed a significant amount of free fluid in
the right flank and within the pelvis which was drained under ultrasound guidance.
Discussion
Anatomy in the region of the gallbladder neck varies mostly in vascular patterns. Aberrant ducts or duct abnormalities are rarely seen during Cholecystectomy highlighting the principle that careful
dissection and identification is the key to safe Cholecystectomy. Variations noted to date include a right hepatic duct opening into the cystic duct, a double cystic duct, anomalous insertion of the
right hepatic duct into the cystic duct, right hepatic duct emptying into the cystic duct. This case shows the diagnostic difficulty in assessing the true biliary anatomy even when ultrasound imaging
was used. The correct delineation of the anatomy was only seen during laparoscopic Cholecystectomy with an operative cholangiogram. This atypical anatomical variation could have resulted in
significant problems to the unwary surgeon. In this case, there was suspicion of a leak but the fluid collected required no further treatment than simple drainage. A per-operative cholangiogram
should be performed when there is any doubt about the biliary anatomy.
Differential Diagnosis List
Cystic duct arising from the right bile duct
Final Diagnosis
Cystic duct arising from the right bile duct
References
[1]
Yamamoto S, Sakuma A, Rokkaku K, Nemoto T, Kubota K. Anomalous connection of the right hepatic duct into the cystic duct: utility of magnetic resonance cholangiopancreatography.
Hepatogastroenterology. 2003 May-Jun; 50(51):643-4. (PMID: 12828051)
[2] Kayahara M, Oyama K, Kitagawa H, Ohta T, Miwa K. Right hepatic duct opening into the cystic duct: the role of pre- and intraoperative cholangiography. Hepatogastroenterology. 2005 May-Jun; 52(63):719-21. (PMID: 15966190)
[3] Hirono Y, Takita Y, Nitta N, Hashimoto H. Double cystic duct found by intraoperative cholangiography in laparoscopic Cholecystectomy. Surg Laparosc Endosc. 1997 Jun; 7(3):263-5. (PMID: 9194293)
[4]
Nomura T, Shirai Y, Sasagawa M, Wakai T, Hatakeyama K. Anomalous insertion of the right hepatic duct into the cystic duct: report of a case diagnosed before laparoscopic Cholecystectomy.
Surg Laparosc Endosc Percutan Tech. 1999 Jun; 9(3):211-2. Review. (PMID: 10804003)
[5] Hashimoto M, Hashimoto M, Ishikawa T, Iizuka T, Matsuda M, Watanabe G. Right hepatic duct emptying into the cystic duct: report of a case. Surg Endosc. 2002 Feb; 16(2):359. Epub 2001 Nov 16. (PMID: 11967701)
Case information
| URL: | https://eurorad.org/case/6304 |
| DOI: | 10.1594/EURORAD/CASE.6304 |
| ISSN: | 1563-4086 |
Figure 2
Cholangiogram
Red arrow marks position of cystic duct arising from right bile duct. This is an anatomical variant.
Figure 3
Anatomical Variants
Anatomical variants of the biliary system. NB. The cystic duct arising from the right bile duct is a variant that has been rarely cited in the past literature.
Normal Anatomy
Figure shows the normal anatomy
Cholangiogram
Red arrow marks position of cystic duct arising from right bile duct. This is an anatomical variant.
Anatomical Variants
Anatomical variants of the biliary system. NB. The cystic duct arising from the right bile duct is a variant that has been rarely cited in the past literature.