Perforation of the extrahepatic bile duct is extremely rare and is described mainly in infants due to congenital anomalies of common bile duct . Very few cases of bile duct perforation have been reported in adults.
Ultrasound findings in CBD perforation are free intra-peritoneal fluid with normal intra and extra-hepatic ducts. Failure to demonstrate the gallbladder reflects decompression of the biliary system due to leakage through perforation. In doubtful cases, the diagnosis can be confirmed with a radioisotope scan. However, in the present case, the diagnosis was made intraoperatively.
Recommended treatment for such cases is T-tube drainage of the common bile duct along with cholecystectomy. In cases with distal obstruction of the CBD, a biliary enteric bypass should be done. Primary suture repair of the CBD is considered unnecessary and even hazardous due to local inflammation.
Spontaneous common bile duct (CBD) perforation is an unusual cause of acute abdomen. It is rarely suspected or correctly diagnosed preoperatively. Clinical presentation is as biliary peritonitis. The common causes are CBD calculus disease, tumors of the bile duct, choledochal cyst and sometimes idiopathic. Treatment is surgical and consists of CBD exploration and repair over a T tube.
A 50 year-old-female patient presented with sudden onset acute abdominal pain and distension with vomiting, and non-passage of flatus and stool for five days. On examination she was pale, tachypnic and dehydrated, with tachycardia and hypotension. The abdomen was distended and tender. Shifting dullness was present but liver dullness was not masked. An abdominal paracentesis examination revealed biliary fluid. No free gas was found under the diaphragm in abdominal X-ray film done in erect posture. A provisional diagnosis of peptic perforation was made, and she was explored after resuscitation. Operative findings included two liters of bile-stained purulent fluid with pus flakes, gall bladder was thick walled and contained multiple calculi without any evidence of perforation. The stomach and duodenum were unremarkable. A single 0.5 cm × 0.5 cm free perforation was present in the anterolateral surface of supraduodenal portion of the common bile duct about 1 cm distal to cystic duct and common hepatic duct confluence. The common bill duct was not dilated and contained multiple stones. A cholecystectomy was done and the CBD was explored. Multiple small stones were removed, irrigation was done with warm normal saline, the patency of the ampulla was checked and the CBD was closed over a T-tube inserted through the site of perforation. The peritoneal cavity was irrigated with warm normal saline. The abdomen was closed after inserting a suction drain in the hepatorenal space.
The pathogenesis of spontaneous bile duct perforation is poorly understood, likely related to its rarity. It is currently thought to be related to multiple factors including increased intraductal pressure, fluid stasis, dilation of the bile duct (due to distal obstruction or spasm of the sphincter of Oddi), diverticulum, abnormal glands in the bile duct wall, infection of the bile duct, a connective tissue defect, or ischemic compromise, and occasionally malignancy [  ,  ,  ,  ].
Laboratory studies also demonstrated a marked change. Canalicular enzymes were slightly elevated: total bilirubin 1.4 mg/dL, direct bilirubin 0.8 mg/dL and alkaline phosphatase 135 IU/L. Complete blood count demonstrated significant leukocytosis of 13,100 WBCs/uL with a left shift of 91.5%. Amylase and lipase were also elevated at 1702 IU/L and 1737 IU/L, respectively.
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.
Hepatobiliary scintography ( Fig. 3 ) revealed tracer accumulation in the subhepatic and perihepatic spaces, indicating bile leak. Image guided paracentesis aspirated 30cc of bilious fluid, and an 8.5 French catheter was placed for further drainage. Fluid studies on the aspirated fluid revealed amylase of 9750 IU/L with negative cultures.
2. Presentation of case
Two weeks of nonoperative management led to minimal improvement in clinical condition, and subsequent operative exploration revealed necrotic CBD with an intact, healthy gallbladder. The CBD was resected and a roux-en-y choledochojejunostomy with common hepatic duct to jejunum anastomosis was created. The patient recovered well.
A 28 year-old female presented to the emergency department, complaining of postprandial epigastric pain that was associated with nausea and emesis. She denied fever and chills. Her past medical history was significant for gastroesophageal reflux disease as well as hypothyroidism. Abdominal exam was non-tender with negative Murphy’s sign. Laboratory studies were significant for transaminitis: AST 343 mg/dL and ALT 490 mg/dL. However, canalicular and pancreatic enzyme and leukocyte levels were within normal levels.
A: Side by side comparison of axial slices of abdominopelvic computed tomography (CT A/P). Left image is admission CT scan, Right image is repeat CT after common bile duct perforation with new demonstration of ascites (WHITE ARROWS). B: Side by side comparison of coronal cuts of CT A/P. Left image from admission CT and Right image from repeat CT after perforation with ascites in lesser sac (WHITE ARROWS).
Furthermore, the lab abnormalities present during work up after the perforation occurred are not surprising after the diagnosis of perforation to the biliary tree. However these lab results also commonly occur in other clinical entities such as gallstone pancreatitis and perforated peptic ulcerations. Imaging abnormalities witnessed in our patient and other previous case reports in conjunction with this pattern of laboratory parameters (canilicular enzyme elevations in combination with elevated amylase and lipase) should doubly prompt suspicion for a primary perforation of the biliary tree.
A high degree of suspicion must be maintained for this unusual clinical entity, especially for the patient that presents with abrupt change in exam and lab parameters with suspected choledocholithiasis as delay in diagnosis is associated with increased morbidity and mortality.