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Spontaneous perforation of the common bile duct mimicking choledochal cyst.

Patient Description A 1 month old male was admitted be‐ cause of abdominal distension and pain that had gradually worsened over the preceding 2 weeks. On examination, the upper abdomen was moderately distended and tender, with suspicion of a mass on palpation. The stool was yellow‐green in color. The rest of the examination was normal. His white blood count was 19,700, total bilirubin 1.5 mg/dl, direct bilirubin 1.1 mg/dl, gamma‐glutamate transferase 320 u/L, alkaline phosphatase 197 u/L, and lactic dehydrogenase 259 u/L. The rest of the liver function tests were within normal limits. Abdominal ultrasound was followed by computerized tomography [Figure A] which demonstrated a large cyst in the upper mid‐abdomen, connected to a mildly dilated common bile duct. Biliary scintigraphy revealed normal hepatic uptake and excretion, but most of the excreted material accumulated in a well‐ defined structure next to the CBD. The child was diagnosed as having a chole‐ dochal cyst and scheduled for surgery. At laparotomy, a 10 cm diameter pseudocyst filled with clear biliary fluid was found in the lesser sac. The CBD was perforated at its junction with the cystic duct. The perforation was oval, 1.1 cm long and 0.4