Preoperative cholangioscopic identification of traumatic type IVa choledochal cyst perforation after motor vehicle collision: A case report

Figure 1  Coronal computed tomography of the abdomen showing a hyperdense filling defect in the common bile duct (arrowhead).

Figure 2 Direct visualization of biliary tract via endoscopic retrograde cholangiopancreatography with fluoroscopy. A: Fluoroscopic image showing a large filling defect in the lower and middle third of the main bile duct (orange circle); B: Fluoroscopic image showing contrast extravasation and the guide wire escaping the normal confines of the biliary architecture, concerning for bile duct perforation (orange circle).

Figure 3 Direct visualization of biliary tract via endoscopic retrograde cholangiopancreatography with cholangioscopy. A: Cholangioscopic image showing partial suction of a large blood clot in the middle third of the common bile duct (CBD). The proximal bile duct could not be visualized beyond this point due to the large clot; B: Cholangioscopic image showing mucosal erythema in the CBD; C: Cholangioscopic image showing an intraductal guide wire in the distal CBD with active bleeding, concerning for hemobilia.

Figure 4 Cholecystostomy cholangiogram showing common bile duct extravasation. Fluoroscopic images obtained via injection of contrast through percutaneously placed cholecystostomy tube. A: Early-phase image showing opacification of the gallbladder and proximal biliary tree, confirming the appropriate position of the tube; B: Progressive-phase image obtained with continued contrast injection, demonstrating extravasation of the contrast into an irregular, poorly marginated collection consistent with perforation of the bile duct and active bile leak.

Figure 5 Timeline of overall diagnosis and treatment course. CT: Computed tomography; ERCP: Endoscopic retrograde cholangiopancreatography; CBD: Common bile duct.