Perforated choledochus cyst

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 perforation of the common bile duct in an adult

Spontaneous perforation of the bile duct is a rare disease in children and even rarer in adults. Although diagnostic techniques have advanced over the past years, yet most cases are diagnosed at operation. A 44-year-old woman presented with epigastric pain and vomiting of one-day duration. Abdominal distension with tenderness and guarding was present all over the abdomen. Abdominal ultrasonography showed free fluid in the peritoneal cavity with sluggish peristalsis. Abdominal and chest radiographs were normal. At laparotomy, common bile duct CBD was perforated at the junction of CBD and cystic duct. Cholecystectomy with CBD exploration was done and CBD was closed over a T-tube, and external drainage was carried out. The patient recovered well, and on the 12th postoperative day, a T-tube cholangiogram was performed which was normal. The T-tube was removed on the 14th postoperative day. One month after operation, the patient was well. Examining the patient with a suspicious thinking helps in early diagnosis and management of the patient.

Biloma: An unusual complication in a patient with pancreatic cancer

The term biloma describes an encapsulated collection of bile within the abdomen, usually secondary to bile duct disruption. The commonest causes reported in the literature are iatrogenic (secondary to hepatobiliary surgery), trauma or complications due to choledocholithiasis. A few cases have been reported as complications of cholangiocarcinoma or acute cholecystitis. We report the case of a 64-year-old man initially diagnosed with a non-obstructive malignancy of the pancreas, who developed a spontaneous intrahepatic biloma 8 mo later. This was identified following a 1-wk history of fever, rigors and icterus. The biloma was identified on computed tomography and subsequently drained under ultrasound guidance. Forty-eight hours later, a stent was inserted endoscopically into his common bile duct and he made an uneventful in-hospital recovery. We believe this is the first documented case of spontaneous intrahepatic biloma to occur secondary to pancreatic malignancy.

Spontaneous perforation of common bile duct: a rare complication of choledocholithiasis

A 35-year-old female presented with 48 hrs history of severe upper abdominal pain and abdominal distension. The patient was suffering from intermittent episodes of colicky upper abdominal pain and spiky fever with chill and rigor in association with yellowish discoloration of eyes and urine for last 3 months. On examination the lady was dehydrated, icteric, febrile and was having tachycardia and hypotension. Abdominal examination indicated features of generalized peritonitis. Hematological profile suggested neutrophilic leukocytosis, blood biochemistry suggested conjugated hyperbilirubinemia, raised alkaline phosphatase and transaminases. Skiagram of the abdomen showed ground glass opacity without any free gas under the diaphragm. Ultrasonography and contrast enhanced CT scan of the abdomen revealed multiple calculi within a distended, thick walled gall bladder, dilated common bile duct (CBD) with a 12.8 mm stone impacted at its lower end and free fluid in the lesser sac and rest of the peritoneal cavity. Diagnostic abdominal paracentasis showed heavily bile stained fluid. Exploration done for generalized biliary peritonitis with sepsis, revealed erosion at the posterior aspect of the retro-duodenal CBD over the site of the impacted stone. She underwent cholecystectomy, choledocholithotomy through a supra-duodenal choledochotomy, and T-tube drainage of the CBD. She made a slow but steady post operative recovery and was discharged from the hospital after 22 days in favorable conditions.

Hepatic disorders severely affected by pregnancy: medical and obstetric management

Hepatic disorders severely affected by pregnancy include choledochal cysts that can be compressed by the gravid uterus and potentially rupture; hepatic adenomas that exhibit accelerated growth because of hyperestrogenemia during pregnancy; acute intermittent porphyria that is exacerbated by increased female sex hormones during pregnancy; splenic artery aneurysms that can rupture during pregnancy because of compression by the gravid uterus; Budd-Chiari syndrome that is promoted by hyperestrogenemia; and hepatitis E and herpes simplex hepatitis that are particularly severe during pregnancy. Hepatic disorders unique to pregnancy include intrahepatic cholestasis of pregnancy; acute fatty liver of pregnancy; preeclampsia and eclampsia; and hemolysis, elevated liver function tests, and low platelet count (HELLP) syndrome. Most disorders uniquely related to pregnancy are treated by prompt fetal delivery as soon as the fetus is sufficiently mature.

Choledochal cyst: a 14-year surgical experience with 36 patients

The presentation and management of 36 patients with cystic dilatation of the biliary tree seen over a 14-year period is reviewed. There were 28 females and 8 males, a ratio of 3.5:1. The classic triad of jaundice, pain and an abdominal mass was seen in only seven cases. Twelve patients suffered recurrent pancreatitis. There were three cases of variceal haemorrhage from portal hypertension secondary to biliary cirrhosis, and one case of biliary peritonitis from a ruptured cyst. Internal drainage (cystenterostomy) was performed in nine patients but five of these eventually needed cyst excision. Cysts have been excised primarily in the last 21 consecutive patients without mortality. Preliminary external drainage with T tubes was used before cyst resection in three patients who presented with complications of choledochal cysts. Cyst excision and hepaticojejunostomy is now the definitive treatment of choice.

Congenital choledochal cyst. Analysis of 1,433 patients in the Japanese literature

Five of the author's cases and 1,428 cases from Japan's literature are discussed. Half of the patients were infants. The ratio of men to women was 1 to 3. One hundred fifty-one patients had malformation of the pancreaticobiliary system, which is said to be a cause of congenital choledochal cyst. All of the patients have been followed up. Excision of the cyst is the best procedure for preventing ascending cholangitis and cystic cancer. Roux-Y hepaticojejunostomy is also effective for reconstruction of the bile duct because it rarely causes ascending cholangitis.

Ruptured choledochal cyst: recognition and management

A case is described of the rupture of a choledochal cyst in a 21-year-old man involved in a motor vehicle accident. At laparotomy, a haemoperitoneum was traced to a large haematoma in the lesser omentum which extended into the mesocolon and was found to be tinged with bile. Eventually it became apparent that the primary pathological condition was a large choledochal cyst into which opened the gallbladder. This cyst had split longitudinally down its anterior surface from the porta hepatis to the duodenum. Bile leakage was controlled by inserting a Foley catheter into the common hepatic duct, and inflating the balloon. Postoperative cholangiography showed massive cystic dilation of the intrahepatic ducts. Five days after the initial operation, a Roux-en Y cystjejunostomy was performed, and the patient has been well since. Crucial points in the emergency management of this condition appear to be in its recognition, and the provision of an adequate method of primary biliary drainage, if the condition of the patient demands staged management. End-to-end cystjejunostomy provides a satisfactory method of final drainage.

Biliary cysts

This review brings the total number of biliary cysts reported in the world literature to 955. Eighty-one per cent of patients are females and 61% were discovered before age ten. The classical triad of right upper quadrant pain, right upper quandrant mass, and juandice is present in 38% of cases. The duration of symptoms prior to diagnosis ranged from less than one week to more than 40 years. The etiology is multifaceted and evidence of the existence of both acquired and congenital cysts is presented. The most useful diagnostic tool is fiberoptic endoscopy with retrograde contrast injection of the common bile duct and pancreatic duct. The incidence of biliary carcinoma in patients with biliary cysts is found to be 2.5%; 24 cases have been reported. Considerable controversy has existed concerning the best operative procedure for biliary cysts; no treatment or medical treatment yielding a 97% mortality rate. In an analysis of 235 patients presented since 1968 with an average followup of 5.2 years, the best procedure appears to be excision with either choledochocholedocostomy or Roux-en-Y hepaticojejunostomy. The operative mortality for all procedures is now 3 to 4%.