Bullet in the common hepatic duct: a cause of obstructive jaundice

The case of the disappearing bullet: An extraluminal compression of the biliary tree

Penetrating abdominal injuries, especially from gun shot wounds, are a common occurrence in South African hospitals, and a vast majority of these patient receive surgical intervention for suspected intra-abdominal injuries. Not all bullets are found and removed however, and we detail the case of a gentleman who presented to our institution with obstructive jaundice secondary to an extraluminal compression of his biliary tree by a retained migrated bullet, that spontaneously resolved, without any surgical intervention.

Late cholestatic syndrome due to previous perforating trauma: Case report

INTRODUCTION

The presence of a foreign body obstructing the bile duct may appear through a typical picture of cholangitis, usually caused by the presence of gallstones.

PRESENTATION OF CASE

Male patient, 31 years old, involved an in accident with gunshot in 2006, injured in the abdominal region. Evolved to a picture of intense pain in the right hypochondrium, mainly after fat meals, without irradiation 12 years after being injured. Presented jaundice episode associated to fecal acholia, choluria, pruritus and sporadic fever. It was diagnosed cholangitis due to the foreign body like a bullet, located in the hepatic duct after tomography performed for investigation. The conduction of the case is described next.

DISCUSSION

Cholestatic syndrome caused by gun bullet in a prior event to the symptoms is a rare event in the literature. Total, there are 8 case reports of bullets found in bile ducts with distinct evolution time among themselves. The first exam will not necessarily identify the bullet, but it simplifies the visualization of the bile ducts dilation, characterizing obstruction.

CONCLUSION

The presence of a foreign body in the bile ducts is well reported in literature, and it is directly dependent on previous history. We should always avoid using cholangioresonance in dubious cases. To keep the ERCP as initial treatment is recommended due to the advances on the procedure quality, but in more severe cases or lack of resources, the surgical exploration is still indicated.

A novel combined interventional radiologic and hepatobiliary surgical approach to a complex traumatic hilar biliary stricture

INTRODUCTION

Benign strictures of the biliary system are challenging and uncommon conditions requiring a multidisciplinary team for appropriate management.

PRESENTATION OF CASE

The patient is a 32-year-old male that developed a hilar stricture as sequelae of a gunshot wound. Due to the complex nature of the stricture and scarring at the porta hepatis a combined interventional radiologic and surgical approach was carried out to approach the hilum of the right and left hepatic ducts. The location of this stricture was found by ultrasound guidance intraoperatively using a balloon tipped catheter placed under fluoroscopy in the interventional radiology suite prior to surgery. This allowed the surgeons to select the line of parenchymal transection for best visualization of the stricture. A left hepatectomy was performed, the internal stent located and the right hepatic duct opened tangentially to allow a side-to-side Roux-en-Y hepaticojejunostomy (a Puestow-like anastomosis).

DISCUSSION

Injury to the intrahepatic biliary ductal confluence is rarely fatal, however, the associated injuries lead to severe morbidity as seen in this example. Management of these injuries poses a considerable challenge to the surgeon and treating physicians.

CONCLUSION

Here we describe an innovative multi-disciplinary approach to the repair of this rare injury.