Peritonitis by perforation of the gall bladder of typhoid origin in children

Peritonitis by perforation of the gall bladder of typhic origin is a rare condition. In Côte d'Ivoire, no studies to our knowledge have addressed the vesicular complications of typhoid fever in children. The aim of this work was to describe the epidemic-clinical, therapeutic and evolutionary aspects of the perforation of the gall bladder of typhic origin in subjects under 15 years of age. In 6 years, five children showed a vesicular perforation of typhic origin or 9.4% of peritonites of typhic origin. They were 5 boys with an average age of 07.4 years 5-11 years. The children were from low socioeconomic backgrounds. No history was noted. Clinical examination revealed peritoneal syndrome. X-ray of the abdomen without preparation carried out in all children had objectified a diffuse greyness. Leucocytosis was present in all cases. Treatment in all children initially consisted of resuscitation and antibiotic therapy with the 3^rd generation cephalosporin and an imidazole. Surgical exploration revealed gangrene and perforated gallbladder without damage to other organs or the presence of stones. A cholecystectomy was performed. The following procedures were simple in 4 patients. A patient died of sepsis following postoperative peritonitis by biliary fistula. Perforation of the gall bladder of typhic origin is rare in children. It is usually discovered at the stage of peritonitis. The treatment combines antibiotic therapy and cholecystectomy. Systematic screening should reduce the progression to this complication.

Biliary peritonitis after endoscopic retrograde cholangiopancreatography

Occurrence of a perforation after endoscopic CPRE sphincterotomy is a complication previously reported in the literature, with frequent repercussions on the duodenum and the periampullary region (Stapfer types 1 and 2); treatment modalities are strictly codified. During an endoscopic procedure, it may be associated with manipulation of a guide wire, generally leading to isolated pneumoretroperitoneum (Stapfer type 4), which is conservatively treated. Secondarily to endoscopic maneuvers, Stapfer type 3 may also occur, causing pancreatic or biliary ductal lesions. When perforation is highlighted following an endoscopic procedure, treatment depends on the presence of an intraperitoneal or retro-peritoneal liquid or aerial effusion. When perforation is contained and clinical tolerance remains satisfactory, conservative treatment is carried out. Conversely, in the event of poor tolerance or intraperitoneal contamination, emergency surgery is called for.

Obliterative cholangiopathy in acquired cystic biliary atresia type III after cyst perforation: a case report

Background

In biliary atresia, the disease process of obliterative cholangiopathy may begin in the perinatal period; however, no chronological evidence exists on how the cholangiopathy progresses to biliary obliteration.

This is the first acquired case with the final diagnosis of type III cystic biliary atresia with an extrahepatic biliary cyst which showed the progression of obliterative cholangiopathy in chronological order after birth.

Case presentation

An 81-day-old girl presented with acute abdominal distress due to bilious peritonitis caused by biliary cyst perforation, for which she underwent emergency biliary drainage. Postoperative images showed a dilated common bile duct and hepatic ducts bilaterally, with flow of the contrast medium to the duodenum through the dilated common bile duct. Biochemistry of the bile collected during and after the operation revealed elevated levels of pancreatic enzymes in the bile from the gallbladder. The patient was diagnosed as having a congenital choledochal cyst and underwent laparotomy at 120 days of age which revealed that she had pancreaticobiliary maljunction. The biliary cyst was resected at the narrow portion just above the junction with the main pancreatic duct. During dissection up to the hepatic hilum, we found that the hilar hepatic ducts were bilaterally replaced by fibrous tissue and were obstructed, leading to a diagnosis of type III a1, μ biliary atresia. The fibrous tissue was excised, and hepatic portoenterostomy was performed according to the Kasai procedure. The patient’s postoperative course was uneventful and the jaundice resolved within 1 month. She has had normal liver function tests with no episode of cholangitis for 3 years after discharge.

Conclusions

We demonstrated the process of acquired type III biliary atresia in a patient with cystic biliary atresia and biliary cyst perforation. To the best of our knowledge, this is the first case of acquired cystic biliary atresia showing chronological progression of the course of obliterative cholangiopathy, providing a better understanding of the development of type III biliary atresia as an acquired disease.

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.

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.

Usefulness of laparoscopic cholecystostomy in children with complicated choledochal cyst

INTRODUCTION

In children with choledochal cysts (CC), obstruction of the discharge of bile or pancreatic juice is frequently observed, and biliary perforation and severe pancreatitis may occur. In such cases, temporary drainage is necessary to stabilize these patients. We employed laparoscopic cholecystostomy followed by laparoscopic cyst excision in cases with complicated CC.

METHODS

Between 2009 and 2013, emergency laparoscopic cholecystostomy for bile drainage was performed in seven girls with complicated CC in whom conservative treatment failed to ameliorate abdominal pain, vomiting, and jaundice; among these seven patients included two with biliary perforation, one with a huge cyst, and four with peribiliary edema suggestive of impending biliary rupture. Protein plugs in the common channel or the terminal portion of the cyst were present in six patients.

RESULTS

Amelioration of symptoms, such as abdominal pain and jaundice, was achieved in all patients after laparoscopic cholecystostomy. Saline irrigation of the bile duct via cholecystostomy was commenced 2 days postoperatively. All patients underwent laparoscopic cyst resection after improvement of their general condition and detailed evaluation of the intrahepatic and extrahepatic bile ducts and pancreaticobiliary maljunction. Impacted protein plugs or gallstones were eliminated in all patients by the time of laparoscopic cyst excision.

CONCLUSION

Laparoscopic cholecystostomy followed by laparoscopic cyst excision is a useful and safe procedure for the treatment of complicated CC. This technique is also favorable from a cosmetic viewpoint because the resultant wound can be reused as the trocar insertion site at the time of laparoscopic cyst excision.