Spontaneous common bile duct perforation-A rare clinical entity

Spontaneous perforation of the common hepatic duct in a child: an unexpected intraoperative encounter

Spontaneous or idiopathic bile duct perforation is rare, mostly seen in children from 25 weeks of gestation to 7 years of age, with the confluence of cystic duct and common hepatic duct (CHD) being the most common site. The exact aetiopathogenesis remains elusive and poorly understood, leading to a lack of consensus on its optimal management. The condition is often diagnosed intraoperatively. We present a case of spontaneous perforation of the CHD in a boy in his middle childhood, alongside a review of relevant literature. The patient presented with acute abdomen and pyobiliary peritonitis, for which a hollow viscus perforation was suspected. An emergent laparotomy revealed a 0.5 cm CHD perforation. Surgical intervention involved T-tube insertion and drainage, leading to a successful recovery. This case underscores the challenge of preoperative diagnosis, necessitating prompt exploration after initial resuscitation. There is a need for clinical vigilance and tailored surgical approaches.

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.

Obstructive-Type Jaundice without Bile Duct Dilatation in Generalized Peritonitis Is a Specific Sign of Spontaneous Gall Bladder Perforation

Generalized peritonitis caused by spontaneous gall bladder perforation is rare and difficult to diagnose preoperatively. The increased absorption of the spilling conjugated bile from the gall bladder by the inflamed peritoneum causes jaundice and direct hyperbilirubinemia. A 56-year-old male patient with septic generalized peritonitis and obstructive-type hyperbilirubinemia came to our hospital. The blood examination showed that total, direct, and indirect bilirubin were 6.20, 5.38, and 0.82 mg/dl. The gall bladder perforation was not detected on USG, CT scan, and MRCP. On laparotomy, we found a 0.5 cm perforation on the fundus of the gall bladder and 2500 cc of bilious fluid in the peritoneal cavity. Cholecystectomy was performed, and the patient completely recovered after the surgery. Preoperative diagnosis of spontaneous gall bladder perforation is difficult even by using ultrasonography, CT scan, and MRCP. The inflammatory reaction of the peritoneum in bile peritonitis increases the absorption of the spilled conjugated bile from the peritoneal cavity. The obstructive-type hyperbilirubinemia without dilatation of the bile duct on imaging examination was the sign of bile leakage into the peritoneal cavity. In septic condition, the preoperative diagnosis of the spontaneous gall bladder perforation is important to establish so that the surgeon can make only a minimal procedure in reducing the morbidity. Therefore, it could be concluded that the presently occurring obstructive-type jaundice without dilatation of the bile duct in the case of generalized peritonitis is a specific sign of spontaneous gall bladder perforation.