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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 14  |  Issue : 2  |  Page : 46-48

Spontaneous common bile duct perforation in an adult female patient presenting with severe epigastric pain mimicking acute pancreatitis


1 Department of Tropical Medicine, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
2 Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assiut, Egypt

Date of Submission29-Apr-2016
Date of Acceptance28-Jul-2016
Date of Web Publication21-Oct-2016

Correspondence Address:
Muhammad Abd El-Gawad Shawky
Department of Tropical Medicine, Faculty of Medicine, Al-Azhar University, Assiut, 71524
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-1693.192649

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  Abstract 

Spontaneous common bile duct (CBD) perforation is a rare event, and mostly occurs in infants with CBD stones and rarely occurs in adults. A 19-year-old female patient presented to us with severe acute epigastric pain mimicking acute pancreatitis, together with vomiting, abdominal distention, and tenderness. Abdominal radiograph and upper gastrointestinal tract endoscopy were normal. Abdominal ultrasound and computed tomography showed retroperitoneal collection near the pancreas. Diagnostic aspiration showed greenish yellow turbid aspirate with very high bilirubin in ascitic fluid than in serum. The case complicated with biliary peritonitis. Laparotomy was performed, and revealed posterior CBD perforation. Peritoneal washing was carried out with removal of about 6 l of bile. Cholecystectomy with CBD exploration was performed, and the CBD was closed over a T-tube and external drainage was carried out. The patient stayed in hospital for 17 days postoperatively and was discharged after removal of the T-tube and drain. She came for follow-up after 1 month from discharge in a very good general condition.

Keywords: adult, common bile duct, perforation, spontaneous


How to cite this article:
Shawky MA, Hassan AM, Mohammed MF, Moustafa HM, Mohammed AMA, Eid MA. Spontaneous common bile duct perforation in an adult female patient presenting with severe epigastric pain mimicking acute pancreatitis. Al-Azhar Assiut Med J 2016;14:46-8

How to cite this URL:
Shawky MA, Hassan AM, Mohammed MF, Moustafa HM, Mohammed AMA, Eid MA. Spontaneous common bile duct perforation in an adult female patient presenting with severe epigastric pain mimicking acute pancreatitis. Al-Azhar Assiut Med J [serial online] 2016 [cited 2019 Sep 22];14:46-8. Available from: http://www.azmj.eg.net/text.asp?2016/14/2/46/192649


  Introduction Top


Common bile duct (CBD) perforation is mostly caused by stones, postoperative leakage, choledochal cysts, after endoscopic retrograde cholangiopancreatography (ERCP), abdominal trauma, or due to cholangitis [1]. However, spontaneous CBD perforation is an extremely rare entity in adults. The first reported case of spontaneous extrahepatic bile duct rupture was in 1882, diagnosed at autopsy [2]. Since then, there are few reported cases of spontaneous CBD perforation, and most cases were in children [3],[4],[5]. The clinical presentation of CBD perforation varies, and because of its rarity the diagnosis is usually delayed. We herein present a case of successfully treated spontaneous CBD perforation in an adult female patient who presented with acute abdominal pain resembling acute pancreatitis.


  Case report Top


A 19-year-old female patient presented to the Department of Tropical Medicine, Al-Azhar Assiut Hospital, with severe epigastric pain referred to the back and loins that increased in supine position and decreased when leaning forward; it was of acute onset, had a progressive course, and was associated with vomiting. Examination revealed average body built female patient with tinge jaundice and epigastric tenderness, a scar of caesarian section (50 days ago), and old abdominal scar of removed abdominal lipoma (10 years ago); otherwise, the patient had normal clinical findings. There was no history of abdominal trauma or interventional procedures.

Pelvic-abdominal ultrasound revealed mild retroperitoneal collection near the pancreas. Abdominal erect radiograph, ECG, and upper gastrointestinal endoscopy were normal. Abdominal computed tomography (CT) revealed retroperitoneal collection surrounding the pancreas and extending into the anterior pararenal spaces with mild pelvic collection and no free air ([Figure 1]), suggesting acute pancreatitis. Serum amylase and lipase were normal. Laboratory findings were as follows: serum bilirubin, 3.4 mg/dl; direct bilirubin, 2.1 mg/dl; aspartate transaminase, 25 µ/l (upper limit is 34); alanine transaminase, 76 µ/l (upper limit is 36); normal international normalized ratio, albumin, 4.3 g/dl; hemoglobin, 11 g/dl; white blood cells (WBCs), 9×103/ml; platelets, 555×109/ml; and normal lipid profile. Hepatitis B surface antigen and anti-hepatitis C virus antibodies were negative.
Figure 1: Axial computed tomography of the upper abdomen with intravenous contrast on the second day, showing mild peripancreatic fluid collection extending to the anterior pararenal spaces.

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The patient was managed as acute pancreatitis, with no improvement and progressive deterioration: increased collection, diffuse abdominal pain, jaundice (total bilirubin, 5.4 mg/dl and direct, 4.1 mg/dl), fever, and increased WBC count (14.5×103/ml). Diagnostic paracentesis revealed the following: greenish yellow turbid fluid, ascitic fluid, and WBCs 2800/ml with neutrophils 98% and lymphocytes 2%; amylase in ascitic fluid was within normal ranges and ascitic fluid bilirubin was 25.9 (serum bilirubin 5.4). Hence, biliary peritonitis was diagnosed. We repeated CT of the abdomen, which showed marked loculated turbid collection and some bulky pancreas ([Figure 2]). Aspiration of 4 l of greenish yellow collection from the right upper quadrant was performed to relieve abdominal discomfort. Intravenous antibiotics and antipyretics were given and fever subsided, but collection was still present and was increasing.
Figure 2: Axial computed tomography (CT) of the upper abdomen with intravenous and oral contrast 11 days after previous CT images ([Figure 1]), showing an increased amount of the fluid with loculation in the perihepatic and peripancreatic spaces.

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Surgical exploration was carried out ([Figure 3]), with normal saline injection into the CBD through the cystic duct; saline escaped from the CBD through its posterior wall into the peritoneal cavity. Cholecystectomy was performed and the CBD closed over a T-tube, and an external drain was inserted. The patient stayed in the hospital for 17 days postoperatively, with complete improvement, and was discharged from the hospital. She came for follow-up after 1 month from discharge in a very good general condition.
Figure 3: During operation.

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  Discussion Top


Spontaneous perforation of the CBD is rare in adults, and most reported cases are among children [6]. The predisposing factors for spontaneous perforations are CBD stones, congenital biliary anomalies (choledochal cysts), previous biliary tract surgery [6],[7],[8],[9], post-ERCP [10], and cholangitis [11]. The most common site of CBD perforation is at the junction between the cystic duct and the CBD [3],[7]. Our case is rare in presentation in that the patient was an adult and with no trauma, surgery, stones, abdominal interventions, or congenital anomalies.

Mechanisms leading to spontaneous CBD perforation are unknown but mostly related to one or more of the following mechanisms:

  1. Increased pressure in the CBD [12], or sudden increase in gall bladder pressure, which is transmitted to the CBD, especially if the CBD is short [13].
  2. Compression on the CBD wall [14].
  3. Ischemic necrosis of the wall, due to thrombosis of the supplying vessels [11].


CBD perforation may present clinically in an insidious or acute form. Insidious form is more common and is characterized by progressive painless abdominal distention, jaundice, and clay-colored stool. The acute form is characterized by acute abdominal pain, vomiting, and peritonitis [15]. Moreover, CBD perforation may present clinically as gastric outlet obstruction, but it is very rare [16].

Suspicion of spontaneous CBD perforation is difficult in the absence of predisposing factors. However, it should be kept in mind in the absence of logical causes explaining cases of acute abdominal pain accompanied with free abdominal fluid collection. The preferred preliminary test is abdominal ultrasound or CT, to confirm the presence of free fluid. Diagnostic aspiration with bilirubin testing is sensitive, but not specific. Cholangiography either by means of scintigraphy or magnetic resonance cholangiopancreatography may help diagnosis. However, in our case, the marked intra-abdominal fluid was suspected to impair magnetic resonance cholangiopancreatography and scintigraphy images. ERCP is diagnostic and can be a therapeutic tool in case of CBD perforation by putting a CBD stent to bypass the perforated site. However, in our case, the marked loculated collection, peritonitis, and the indefinite diagnosis, urged us to carry out surgical exploration, for peritoneal wash, intraoperative cholangiography, and to decide accordingly.

Recommended treatment in such cases is CBD stenting through ERCP if perforation is small and discovered early. In diagnosis-delayed cases or large perforations, laparotomy with cholecystectomy and CBD closure over T-tube is sufficient.


  Conclusion Top


Spontaneous CBD perforation is a rare condition in adults, but should be kept in mind due to its potential mortality. Any suspected case after abdominal ultrasound examination, should be subjected to early cholangiography to be treated early.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Treem WR, Hyams JS, McGowan GS, Sziklas J. Spontaneous rupture of a choledochal cyst: clues to diagnosis and etiology. J Pediatr Gastroenterol Nutr 1991; 13:301–306.  Back to cited text no. 1
[PUBMED]    
2.
Freeland J. Rupture of the hepatic duct. Lancet 1882; 119:731–732.  Back to cited text no. 2
    
3.
Chardot C, Iskandarani F, de Dreuzy O, Duquesne B, Pariente D, Bernard O et al. Spontaneous perforation of the biliary tract in infancy: a series of 11 cases. Eur J Pediatr Surg 1996; 6:341–346.  Back to cited text no. 3
    
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Davenport M, Heaton ND, Howard ER. Spontaneous perforation of the bile duct in infants. Br J Surg 1991; 78:1068–1070.  Back to cited text no. 4
    
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Hasegawa T, Udatsu Y, Kamiyama M, Kimura T, Sasaki T, Okada A, Mushiake S. Does pancreatico-biliary maljunction play a role in spontaneous perforation of the bile duct in children? Pediatr Surg Int 2000; 16:550–553.  Back to cited text no. 5
    
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Marwah S, Sen J, Goyal A, Marwah N, Sharma JP. Spontaneous perforation of the common bile duct in an adult. Ann Saudi Med 2005; 25:58–59.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
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Lilly JR, Weintraub WH, Altman RP. Spontaneous perforation of the extrahepatic bile ducts and bile peritonitis in infancy. Surgery 1974; 75:664–673.  Back to cited text no. 7
    
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Kang SB, Han HS, Min SK, Lee HK. Nontraumatic perforation of the bile duct in adults. Arch Surg 2004; 139:1083–1087.  Back to cited text no. 8
    
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Steinhoff NG, Tucker GL. Nontraumatic perforation of the common duct. Am J Surg 1971; 121:334–337.  Back to cited text no. 9
    
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Lai CH, Lau WY. Management of endoscopic retrograde cholangiopancreatography-related perforation. Surgeon 2008; 6:45–48.  Back to cited text no. 10
    
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Suarez L, Detmer DE, Jarrett F. Surgical management of spontaneous hepatic duct perforations. Ann Surg 1981; 194:176–179.  Back to cited text no. 11
    
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Paramhans D, Shukla S, Grover J. Spontaneous perforation of the common bile duct in an adult. Indian J Surg 2013; 75:376–378.  Back to cited text no. 12
    
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Fletcher WS. Nonpenetrating trauma to the gallbladder and extrahepatic bile ducts. Surg Clin North Am 1972; 52:711–717.  Back to cited text no. 13
    
14.
Lee D, Zacher J, Vogel TT. Primary repair in transection of duodenum with avulsion of the common duct. Arch Surg 1976; 111:592–593.  Back to cited text no. 14
    
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Rege SA, Lambe S, Sethi H, Gandhi A, Rohondia O. Spontaneous common bile duct perforation in adult: a case report and review. Int Surg 2002; 87:81–82.  Back to cited text no. 15
    
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Haller JO, Condon VR, Berdon WE, Oh KS, Price AP, Bowen A, Cohen HL. Spontaneous perforation of the common bile duct in children. Radiology 1989; 172:621–624.  Back to cited text no. 16
    


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