Spontaneous perforation of the common bile duct in an adult

Spontaneous perforation of the common bile duct in adults presenting as biliary peritonitis: a case report and literature review

Spontaneous perforation of the common bile duct (SPCBD) is an exceptional disease, especially in adults. The cause is often idiopathic once trauma and choledochal cyst are excluded. Early diagnosis is often difficult because of its often-misleading appearance.

Case presentation

The authors report the case of a 54-year-old man, a known case of type 2 diabetes mellitus, who presented to our emergency department for acute abdominal pain that had evolved for 2 days.

Clinical findings and investigations

On physical examination, the patient had a fever of up to 38.5°C, and the abdomen was distended and generally tight. The abdominal computerized tomography scan confirms the presence of free fluid. In addition, the thickness of the gallbladder wall had increased in contrast with a resolved gallbladder distention. Because exploration failed to demonstrate the cause of ascites, the authors performed a diagnostic paracentesis, which revealing ascites with a dark yellow-green color, which implied bile leakage.After initial resuscitation, an emergent exploratory laparotomy was performed. The authors found biliary peritonitis secondary to SPCBD. After peritoneal lavage, the perforation was repaired over a T-tube. The postoperative course was uneventful. Histological findings were consistent with ulcerous acalculous cholecystitis. The patient was disease-free after a 3-month follow-up.

Discussion

SPCBD is an uncommon condition in adults, and it is rarely reported in the literature. The pathogenesis of this disease is not clear and may be related to single or multiple factors. Usually, this disease is diagnosed in the postmortem. Early diagnosis and optimal surgical treatment are challenging.

Conclusion

This present case highlighted the preoperative diagnostic difficulties of the SPCBD. Emergent surgical management should be instituted in the shortest time possible to reduce the high mortality.

Spontaneous common bile duct perforation due to choledocolithiasis accompanied with pancreaticobiliary maljunction in an adult: a case report

BACKGROUND

Spontaneous common bile duct (CBD) perforation is an extremely rare disease in adults. We report an adult case of CBD perforation due to choledocolithiasis accompanied with pancreaticobiliary maljunction, which is, to our knowledge, the first such case report based on a search using PubMed.

CASE PRESENTATION

A 71-year-old woman with consciousness disorder was transported to the emergency department of another hospital. She was diagnosed as having severe peritonitis with septic shock and transferred to our hospital for emergency surgery. Enhanced computed tomography (CT) revealed supraduodenal CBD dilation similar to a diverticulum and a defect of bile duct wall continuity. Furthermore, CT showed a long common channel of the pancreaticobiliary duct, so she was diagnosed as having spontaneous CBD perforation with pancreaticobiliary maljunction. Emergency surgery was performed that revealed a necrotic diverticulum-like change on the supraduodenal part, and a 2.5 × 1 cm perforation was found on the anterolateral wall of the CBD. Peritoneal lavage was performed, and CBD perforation was resolved with a T-tube. The patient suffered refractory intra-abdominal and retroperitoneal abscess formation and bleeding from the abdominal wall, which required a long period of postoperative management. The T-tube was removed on day 136, and the patient was transferred on day 153.

CONCLUSION

The cause of CBD perforation is commonly considered to be increased intraductal pressure or weakness of the bile duct wall. In this case, pancreaticobiliary maljunction may have significantly influenced onset and the postoperative course. This case suggests that early surgical intervention and appropriate drainage are important to ensure survival.

Biliary Peritonitis Due to Spontaneous Perforation of the Left Intrahepatic Bile Duct in an Adult: A Case Report and Review of Literature

Spontaneous perforation of the left intrahepatic bile duct is extremely rare, especially in adults. Here, we report on a case of a 64-year-old woman who had a complaint of right upper abdominal pain for 10 days, which gradually progressed to entire abdominal pain for 3 days, and was admitted to our hospital. Relevant examinations revealed she had a normal cardiac and lung workup, but an obvious abnormal abdominal computed tomography examination, which revealed an enlarged gallbladder, choledocholithiasis with dilatation of the common bile duct (1.8 cm) and intrahepatic bile duct, and a lot of encapsulated ascites. After being given adequate fluid resuscitation and active preoperative preparation, cholecystectomy and common bile duct exploration and perforation repair operation were then performed. The postoperative course was uneventful, and she was discharged with the T-tube in situ. A choledochoscopy examination at week 6 showed the conditions of the intrahepatic and extrahepatic bile duct were good. For these patients, early diagnosis and surgical treatment are essential for good prognosis. The goal of our surgery is to stop bile leakage, resolve choledocholithiasis and cholangitis, and reconstruct the bile duct.

Spontaneous common bile duct perforation-A rare clinical entity

INTRODUCTION

Spontaneous common bile duct perforation is an uncommon clinical entity in both adults and children. Few case reports have been published since the first clinical description in 1882. Our work has been reported in line with SCARE criteria.

PRESENTATION OF CASE

Herein, we describe the case of a 28 year-old female who suffered spontaneous common bile duct perforation while admitted for choledocholithiasis.

DISCUSSION

The perforation occurred while in-hospital, and extensive imaging and laboratory tests characterized the disease in detail. To our knowledge, this is the first report of spontaneous common bile duct perforation witnessed from pre-perforation through definitive management.

CONCLUSION

Physicians and Surgeons should seek out this uncommon diagnosis in the patient with suspected Choledocholithiasis who suddenly become peritoneal on physical exam so that definitive care can be expedited.

Non-traumatic perforation of common hepatic duct: Case report and review of literature HP

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A rare case of spontaneous perforation of common hepatic duct due to stones impaction.

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Because of its rarity, spontaneous biliary perforation requires high index of suspicion.

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Impacted stones in the biliary tree need to be extracted to avoid complications.

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ERCP and stent placement should be only used as temporizing measures to manage the acute obstructive phase.

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Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones.

Introduction

Non-traumatic biliary perforation other than the gallbladder is extremely rare and most commonly seen in children in association with congenital biliary anomalies. We present a rare case of choledocholithiasis that progressed to spontaneous perforation of the common hepatic duct probably from ischemic necrosis caused by impaction of large biliary stones.

Casereport

A 62-year-old female presented with diarrhea and jaundice. She was found to have two 2.5 cm stones in the common hepatic duct. Stones could not be extracted by ERCP, and placement of biliary stent was done to restore patency. The patient was lost to follow up and returned after three months with a new onset of similar symptoms. At that time ERCP and a stent change were done without resolution of the symptoms. Patient then underwent an open exploration and was found to have a free perforation in the lateral aspect of the common hepatic duct just at the bifurcation of the right and left hepatic radicals. Through this perforation stones were both extracted and cholangiogram showed free flow with the distal biliary stent. The stent was nowhere near the site of perforation which appeared to be caused by pressure necrosis from the impacted stones.

Conclusion

Impacted stones in the biliary tree need to be extracted to avoid pressure necrosis and spontaneous perforation. ERCP and stent placement should be used only as temporizing measures to manage the acute obstructive phase. Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones and avoid complications.