Post written by Mohannad Abou Saleh, MD, Catherine Vozzo, DO, and Prabhleen Chahal, MD, from the Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio.

We describe the EUS diagnosis of a type IIIA choledochal cyst in an 81-year-old woman with a history of diabetes mellitus type II, hypertension, hyperlipidemia, GERD, and irritable bowel syndrome. She presented initially with constipation and abdominal cramping related to her history of mixed-type irritable bowel syndrome. She had a CT scan, which showed a cystic dilation of the distal common bile duct measuring 1.7 cm and extending into the lumen of the descending duodenum. Liver function tests were unremarkable. EGD revealed a bulging of the ampullary region. On EUS examination, an anechoic cystic dilation of the intraduodenal segment of the bile duct is demonstrated with a normal caliber of the bile duct.

Type III choledochal cysts are extremely rare and account for only 1-5% of biliary cysts. Thus, exposure of endoscopists and trainees to this diagnosis is limited. There are few EUS images describing the endosonographic features of type IIIA choledochal cysts, and there are no published video cases to date. By showcasing this video and describing the EUS findings we hope to aid in the detection and diagnosis of choledochal cysts.

Type III choledochal cysts can be detected incidentally in older age. Close follow-up as opposed to endoscopic intervention should be considered if the patient is asymptomatic. The EUS features include anechoic cystic dilation of the intraduodenal segment of the bile duct, with both bile and pancreatic ducts terminating in the cyst. This diagnosis should not be confused with duplication cysts, which often appear as multilayered cysts with epithelial lining and muscularis propria that are continuous with the duodenum. They tend to have an echogenic inner layer with a hypoechoic surrounding layer. 

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