A rare case of spontaneous common bile duct perforation

Abstract

Spontaneous perforation of the common bile duct (CBD) in adults is an extremely rare complication of gallstones. It is challenging to establish the diagnosis pre-operatively however with increasing utility of computer tomography, there may be subtle features visualized. We describe a case of a 35 year old Indian male who presented with an acute abdomen and was found to have biliary peritonitis secondary to a spontaneous CBD perforation. Mr JJ presented with sudden onset of abdominal pain associated with vomiting and diarrhea. He had generalized abdominal peritonitis. Initial erect chest x-ray was unremarkable for free air under the diaphragm, hence a CT was performed which revealed moderate amounts of free fluid around the 2nd part of the duodenum extending along the anterior para-renal space into the pelvis, with a 4mm distal CBD stone resulting in mild upstream dilatation. The gallbladder was decompressed and the CBD wall was not well visualized in the mid-portion, raising the possibility of perforation. An exploratory laparotomy revealed generalized biliary peritonitis secondary to a 2 cm CBD perforation just distal to the cystic duct junction. Choledochoscopy confirmed the small 4mm distal CBD stone which was advanced successfully through the ampulla into the duodenum. He underwent abdominal lavage, cholecystectomy, choledochectomy and a roux-en-Y hepatico-jejunostomy reconstruction. His recovery was uneventful. Histology confirmed focal transmural necrosis of the bile duct with fibrosis and micro-abscess formation. Clinicians should be aware that whilst spontaneous extrahepatic bile duct perforations are rare, it is important as timely diagnosis can be life-saving.