Spontaneous biliary perforation in infancy and childhood: clues to diagnosis

Analysis of the Clinical Characteristics of Spontaneous Bile Duct Perforation in Children

OBJECTIVE

This study aimed to explore the etiology, clinical features, diagnosis, and treatment of spontaneous bile duct perforation (SBDP) in children.

METHODS

The clinical data of children with SBDP who were admitted to Wuhan Children's Hospital between January 2014 and January 2020 were retrospectively analyzed.

RESULTS

In all, 28 cases of children with SBDP (male, 28.6%; female, 71.4%; male-to-female ratio, 1:2.5; average age, 2.15 years) were analyzed. The most common symptoms were fever (85.7%), nausea and vomiting (78.6%), and abdominal distension (67.9%). Among the 28 patients, 26 (92.9%) had elevated hypersensitive C-reactive protein, 24 (85.7%) had an increased neutrophil percentage, and 22 (78.6%) had raised peripheral blood leukocyte counts. Moreover, 19 patients (67.9%) showed increased serum total bilirubin levels, and 5 (17.9%) showed an elevated conjugated bilirubin level. Abdominal CT examination revealed that the gallbladder wall of patients was thickened with edema, accompanied by gallbladder stenosis and gallbladder mucosa enhancement; furthermore, ascites was found in the abdominal cavity and lesser omental bursa. Twenty-two patients underwent abdominal paracentesis, and 20 (90.9%) of them were exposed to bile-based ascites. Among the 28 patients, four recovered with conservative treatment, whereas the others (85.7%) were surgically treated. Of the twenty-four patients undergoing surgery, the perforation site was found at the union of the hepatic and cystic ducts in 12 patients (50%), no perforation site was observed in 9 patients (37.5%), and a common hepatic duct was observed in 3 patients (12.5%). All 24 patients underwent stage I surgery, and temporary biliary drainage was performed because of severe abdominal inflammation. Cholangiography and enhanced CT revealed an abnormal location of the pancreatic duct joining the bile duct in 64.3% patients. Following surgery, 15 patients underwent hepaticojejunostomy. Subsequently, 3-month to 6-year follow-up (median, 30 months) indicated that the patients recovered well with no serious complications.

CONCLUSION

SBDP in children may be associated with pancreaticobiliary malunion (PBM) and congenital weakness of the bile duct wall. However, the clinical manifestations of this condition lack specificity; this limitation can be assisted through diagnosis via abdominal CT and by performing abdominal paracentesis. Once SBDP diagnosis is confirmed, the patient should follow the principles of individualized treatment.

Spontaneous common hepatic duct perforation in a child: A rare case report

Spontaneous perforation of common bile duct is a rare phenomenon; few cases are reported in literature. Hence, there is a dilemma for the management of these cases, but with modern radiological equipment and high degree of suspicion, it is possible to diagnose early. The overall prognosis of this condition is good, provided an early surgical intervention is instituted; we are reporting a case of a 6-year-old male with spontaneous perforation of common hepatic duct. Managed by repair of rent over T-tube, postoperative period was uneventful, T-tube was removed after 3 weeks, and the patient is doing well in follow-up.

A hairy situation: trichobezoar presenting with intussusception, and intestinal and biliary perforation in a child

Trichobezoars are an uncommon cause of acute abdominal pain. We present a case of a 12-year-old girl with a history of a trichobezoar who presented to the emergency department with acute abdominal pain. Abdominal sonography was performed which suggested portal venous gas and showed complex peritoneal fluid. Subsequent computed tomography demonstrated both gastric and small bowel bezoars, with a jejunojejunal intussusception, and confirmed portal venous gas and complex ascites. At the time of surgery, there was evidence of intestinal and biliary perforation. Our case illustrates a constellation of complications in association with a long-standing trichobezoar.

A Case of Biliary Peritonitis following Spontaneous Common Bile Duct Perforation in a Child

Spontaneous common bile duct (CBD) perforation leading to biliary peritonitis is a rare entity in children. It is an unusual cause of acute abdomen and is potentially fatal. Preoperative diagnosis is rare. A 10-year-old girl was referred from a private hospital after laparotomy for acute abdomen. Intraoperatively, bile was found in the peritoneal cavity which was drained, and the patient was referred to Topiwala National Medical College. Endoscopic retrograde cholangiopancreaticography (ERCP) and stenting was done. The stent was removed after 8 weeks, and the girl is doing well during follow-up.

Bile Duct Perforation due to Inspissated Bile Presenting as Refractory Ascites

Non hepatic origin of refractory ascites is not a rarity. Hemolytic anemias are known to cause inspissated bile and biliary obstruction. Distal biliary obstruction can lead to biliary perforation. The authors report a case of hereditary spherocytosis leading to inspissated bile causing bile duct perforation and biliary ascites. A high index of suspicion for biliary ascites should be kept in a child with refractory ascites in the setting of progressive ascites with decreasing bilirubin. Ascitic fluid bilirubin analysis will clinch the diagnosis. Surgical repair is the optimal management.

Spontaneous biliary perforation in infancy: Management strategies and outcomes

PURPOSE

Infantile spontaneous biliary perforation is rare with variable management strategies ranging from nonoperative treatment to complex operations such as biliary-enteric reconstruction. Biliary fistula and portal vein thrombosis are known complications, though outcomes are poorly defined.

METHODS

We assessed the incidence of spontaneous biliary perforation in infants <1 year old using a population database. Next, we describe 4 patients treated at our institution and review all reported cases within the past 25 years.

RESULTS

The incidence of spontaneous biliary perforation is 1.5 in 1,000,000 live births. Over the past 25 years, 90 cases were reported, over half of which were initially managed with a surgical drainage procedure. The most common reason for failure of this strategy was CBD obstruction. Our 4 patients were successfully managed without biliary reconstruction despite 2 presenting with CBD obstruction. Reported complications occurred in 22% of patients, most frequently biliary fistula requiring delayed biliary reconstruction.

CONCLUSIONS

Surgical drainage is an effective method for treatment of infantile spontaneous biliary perforation; however a persistent biliary fistula should prompt evaluation for distal CBD obstruction. Though biliary-enteric anastomosis is the historic procedure of choice for persistent fistula, with improvements in endoscopic and percutaneous treatment, extensive biliary reconstruction may be avoided in the future.

Clinical value of ultrasound in diagnosing pediatric choledochal cyst perforation

OBJECTIVE. The objective of our study was to evaluate ultrasound images of pediatric patients with choledochal cyst perforation and establish imaging findings that can be used as the basis for timely surgical intervention. MATERIALS AND METHODS. Our study group was composed of 23 pediatric patients who presented with various symptoms of acute abdomen and were admitted to our institution between 1996 and 2013. All had undergone preoperative ultrasound examination and had a final diagnosis of choledochal cyst perforation that was confirmed at exploratory laparotomy. The imaging and surgical data were reviewed and analyzed retrospectively. RESULTS. The 23 patients included nine males and 14 females with a mean age of 2.55 years and mean disease duration of 12.48 days. The most common initial diagnoses were intestinal obstruction and peritonitis. Real-time ultrasound imaging with multislice views revealed characteristics of choledochal cyst perforation, including changes in the shape of the bile duct, loss of local gallbladder tension, thickened gallbladder wall, changes in the morphology of the gallbladder, and peritoneal effusion. The inability to visualize the gallbladder, gallbladder enlargement, the presence of gallbladder sludge and of pebblelike stones, and dilatation of the intrahepatic ducts were also noted on ultrasound. Choledochectasia was present in a majority of the patients (17/23), and ascites was seen in all 23 patients. The ultrasound signs corresponded to the surgical findings, thus showing the high clinical diagnostic value of ultrasound in this setting. CONCLUSION. Real-time ultrasound imaging-with its multislice views and good reproducibility-allows definitive preoperative diagnosis of pediatric choledochal cyst perforation.

Spontaneous biliary peritonitis in children

Pediatric Spontaneous Bile duct perforation is a rare clinical condition with only around 150 cases reported worldwide. Early management gives excellent prognosis but the condition often presents a diagnostic dilemma. Hepato-biliary Technetium-99m-iminodiacetic acid scintiscan is the diagnostic investigation of choice but its availability in third world countries is limited. We present two cases of spontaneous biliary peritonitis in children, which were diagnosed without scintiscanning. The first case was a one-and -a half-year-old child, who was diagnosed with biliary peritonitis without pneumoperitoneum by a combination of Ultrasound (USG), Contrast enhanced computed tomography (CECT), and Magnetic Resonance Imaging (MRI). The child underwent USG-guided drainage and subsequent cholecystectomy with hepatico-jejunostomy. The second child also had biliary peritonitis without pneumoperitoneum, which was initially suspected on USG. CECT revealed dilated gall bladder and fluid collection in sub-hepatic space and pelvis. Abdominal paracentesis revealed presence of bile. The child responded to conservative therapy. Both are doing well on two-year follow-up. In a patient with jaundice, biliary tract abnormalities and/or free fluid, either generalized or localized to peri-cholecystic/sub-hepatic space on USG/CT/MRI, in the absence of pneumoperitoneum, suggest a diagnosis of biliary perforation even in the absence of scintiscanning.

Conservative management of spontaneous bile duct perforation in infancy:: case report and literature review

Spontaneous bile duct perforation in infants is rare, with less than 150 cases having been reported worldwide. With a highly variable presentation, diagnosis and treatment can prove challenging, and outcomes are not without significant morbidity. We herewith report the case of an 8-week-old male infant with spontaneous bile duct perforation. He initially presented with abdominal sepsis and septated ascites on ultrasound, which was confirmed as bilious on ascitic tap and at diagnostic laparoscopy. Intraoperative cholangiogram demonstrated a localized leak at the junction of the cystic and common bile duct. Conversion to laparotomy was ultimately required with cholecystostomy, and 2 external intraabdominal drains were placed. He was subsequently managed conservatively with 4 weeks external drainage, with a repeat cholangiogram at 6 weeks, demonstrating successful resolution of the leak. The reported case supports the findings of changing practices in the existing literature. We suggest that, in cases of spontaneous bile duct perforation with no distal obstruction, dissection and surgery to the biliary tree are not always required. Conservative management with simple external drainage can have its complications but, as shown here, can be a successful treatment option in terms of healing of perforation.

Case report: Retroperitoneal biliary fluid collections secondary to common bile duct rupture - an unusual complication of choledocholithiasis in a child

Rupture of the common bile duct (CBD) in a child secondary to choledocholithiasis is a rare event. In this article, the authors describe a child who presented with an acute abdomen due to CBD rupture, with subsequent acute retroperitoneal fluid collections, all diagnosed preoperatively on CT scan. The aim of this article is to show the pathways that such collections can take in the retroperitoneum.

Spontaneous perforation of the cystic duct in streptococcal toxic shock syndrome: a case report

Introduction

Streptococcal toxic shock syndrome is a complication of group A streptococcal infection, most often originating from the skin. The syndrome is characterized by fever, hypotension and multiple organ failure. Mortality rate may be as high as 80%.

Case presentation

A 25-year-old man of Indian origin presented with abdominal complaints, rash and fever after an episode of pharyngitis. The patient was operated and a biliary peritonitis was found caused by perforation of the cystic duct in the absence of calculi. Cholecystectomy was performed, but after the operation, the patient's condition worsened and multi-organ failure developed. Group A streptococci were cultured in blood taken at admission and streptococcal toxic shock syndrome was diagnosed. Treatment consisted of antibiotics, corticosteroids, immunoglobulin and supportive treatment for haemodynamic, respiratory and renal failure.

Conclusion

This is a patient with streptococcal toxic shock syndrome complicated by spontaneous perforation of the cystic duct. Spontaneous perforation of the cystic duct is a rare finding, most often reported in children and secondary to anatomic defects. We found only one similar adult case in the literature. Perforation may be due to microthrombosis and ischaemia, and so be a part of the multi-organ failure often found in streptococcal toxic shock syndrome.