Bullet in the Common Hepatic Duct: a Cause of Obstructive Jaundice

Abstract

A 22 year old man was accidentally shot 32 months prior to referral to our hospital. Two injuries, one in the right upper abdomen and another in the right thigh, were sustained. Emergency surgery took place at a small district hospital. The thigh bullet was removed and exploratory laparotomy was performed. Operative notes made available to us mentioned that there was perforation of the stomach, transection of duodenum, inferior vena cava and common bile duct. Direct repair of the stomach, duodenum and inferior vena cava with gastrojejunostomy and Roux-en-Y hepaticodochojejunostomy were undertaken. There was no mention of the retrieval of the abdominal bullet. The patient was well for 2 months. After this he developed intermittent episodes of jaundice and clay coloured stools. As patient’s symptoms were intermittent and subsided spontaneously, no active surgical or medical management was undertaken. Symptoms continued in this manner for over 2 years, after which the patient was referred to our hospital. On examination the patient was icteric and had mild hepatomegaly and a palpable gall bladder. Laboratory investigation showed raised bilirubin (total: 12 mg% and direct: 9.2 mg%), SGOT (229 IU/l), SGPT (128 IU/l) and alkaline phosphatase (1713 IU/l). Plain radiograph showed an approximately 0.5 £ 1.5 cm bullet-shaped, radioopaque density, projected infero-medially to the inferior margin of the liver (Fig. 1). Ultrasound demonstrated a dilated intrahepatic biliary tree in both the lobes of liver. The common hepatic duct was dilated and contained a 16 mm echogenic focus (Fig. 2). CT confirmed intrahepatic biliary radical dilatation. A dense radio-opaque foreign body in the region of the porta with streak artefact was also noted (not shown). At operation, the gall bladder was normal. A gastrojejunostomy and left hepaticodochojejunostomy were noted. The common bile duct (CBD) was seen to be ligated just above the superior border of the duodenum. A peroperative cholangiogram was performed through the ligated end of the CBD. It revealed the presence of a bullet in the common hepatic duct (at the confluence) causing partial obstruction (Fig. 3). Filling of both lobe biliary