Perforation Of Bile Duct Research Articles

Rupture of intrahepatic bile duct after ERCP for common bile duct stone: A case report of rare complications.

Complications after endoscopic retrograde cholangiopancreatography (ERCP) are diverse and usually treated with nonoperative management or percutaneous drainage; however, there are still some rare, life-threatening complications. This is an extremely rare case of biliary peritonitis caused by rupture of the intrahepatic bile duct after ERCP. A 63-year-old male underwent ERCP for common bile duct stones. On the second day after the procedure, the patient developed sepsis and abdominal distention. Contrast-enhanced computed tomography revealed a subcapsular hepatic fluid collection attached to the bile duct of segment VII. Sepsis resulted in liver parenchyma rupture and intrahepatic bile duct injury after ERCP. Intraoperative cholangiography revealed a connection between a hole in the liver parenchymal surface and the intrahepatic bile duct. Surgeons performed the cholecystectomy, inserted a T-tube into the common bile duct stones, sutured the defect, and put 2 drainage tubes around the lesion. Postoperative recovery was uneventful, and the patient was discharged on the 17th postoperative day. Intrahepatic bile duct perforation after ERCP can lead to rupture of the liver parenchyma, biloma, or abdominal peritonitis. Multidisciplinary management is necessary to achieve favorable outcomes.

Spontaneous perforation of the common bile duct: an uncommon complication of primary sclerosing cholangitis.

To describe the MR features and prognosis of patients with an uncommon complication of primary sclerosing cholangitis (PSC) characterized by a spontaneous perforation of the common bile duct (CBD) resulting in a peri-biliary collection and a pseudo-cystic appearance of the CBD. A single-center cohort of 263 patients with PSC who had at least two MRIs between 2003 and 2022 and a minimum follow-up of 1 year was retrospectively analyzed. MRI data (characteristics of CBD perforation and MR features of PSC) and clinical data were assessed. Analysis of survival without liver transplantation according to type of PSC (classical or CBD spontaneous perforation) was performed according to the Kaplan-Meier method and the curves were compared using the Log-Rank test. A total of nine (3.4%) PSC patients (5 males) had perforation of the CBD with a median age at diagnosis of 18 years compared to 33 years for the control group (p = 0.019). The peri-biliary collections were variable in appearance (fusiform or pedunculated), with a diameter ranging from 5 to 54 mm. All nine patients showed intra- and extra-hepatic bile duct involvement, dysmorphia, and high ANALI scores. The clinical course was characterized by numerous complications in most patients, and five patients (56%) underwent liver transplantation at a median time of 5 years from diagnosis, compared to 40 patients (16%) in the control group (p = 0.02). The spontaneous perforation of the common bile duct is an uncommon complication of primary sclerosing cholangitis that affects young patients and is associated with a poor prognosis. This uncommon complication of primary sclerosing cholangitis with perforation of the common bile duct resulting in a peri-biliary collection and a pseudo-cystic appearance of the common bile duct is characterized by a poor prognosis in younger patients. • Among 263 patients with primary sclerosing cholangitis (PSC), nine patients (3.6%) had an uncommon complication characterized on MRI by perforation of the common bile duct (CBD). • This perforation of the CBD was responsible in all nine cases for the formation of a peri-biliary collection, giving a pseudo-cystic appearance to the CBD. • The spontaneous perforation of the common bile duct is an uncommon complication of primary sclerosing cholangitis that affects young patients with a poor prognosis.

Spontaneous common bile duct perforation: a rare case report

Spontaneous common bile duct (CBD) perforation is a rare and life threatening clinical condition. The course of management and choice of surgical intervention depends on clinical presentation; site, size, nature of defect. It is usually reported in infants and adults due to congenital anomalies and following invasive procedure respectively but spontaneous CBD perforation in older age groups is rare without underlying cause presenting as acute abdomen. In this case report, an 82-year-old female presented to the emergency room with an acute abdomen diagnosed as spontaneous CBD perforation and its prompt management and its successful outcome.

Safety Parameters for the Use of Holmium:YAG Laser in the Treatment of Biliary Calculi: The Ex-Vivo Model.

Background and Objectives: While studies have demonstrated the efficacy of cholangioscopy-guided Holmium-Yttrium aluminum garnet (Ho:YAG) laser lithotripsy for the treatment of refractory bile duct stones, data regarding the safety of the operating parameters for laser lithotripsy are lacking. The aim of this study was to determine safe, yet effective, energy settings for Ho:YAG laser in the ex-vivo model. Materials and Methods: This ex vivo experimental study utilized the Ho:YAG laser on porcine bile duct epithelium and human gallstones. Ho:YAG laser lithotripsy was applied in different power settings from 8 to 15 Watts (W) to six explanted porcine bile ducts. Settings that appeared safe were then utilized to fragment seventy-three human gallstones. Results: The median bile duct perforation times with the Ho:YAG laser between 8-15 W were: >60 s (8 W); 23 s (9 W); 29 s (10 W); 27 s (12 W); 12 s (14 W); and 8 s (15 W). Statistically significant differences in the median perforation times were noted between 8 W vs. 15 W, 9 W vs. 15 W, 10 W vs. 15 W, and 12 W vs. 15 W (p < 0.05). When using a 365 µm Ho:YAG laser probe at 8-12 W, the fragmentation rates on various size stones were: 100% (<1.5 cm); 80-100% (1.6-2.0 cm) and 0-32% (>2.0 cm). Optimal fragmentation was seen utilizing 12 W with high energy (2.4 J) and low frequency (5 Hz) settings. Using a larger 550 µm probe at these settings resulted in 100% fragmentation of stones larger than 2 cm. Conclusions: The Ho:YAG laser appears to be safe and effective in the treatment of large bile duct stones when used between 8-12 W in 5 s bursts in an ex vivo model utilizing porcine bile ducts and human gallstones.

The Impact of Frailty on ERCP-Related Adverse Events: Findings From a National Cohort

Background and AimsEndoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that has evolved from being primarily diagnostic to predominantly therapeutic, leading to an increased potential for ERCP-related adverse events. Frailty is an independent predictor of adverse outcomes, and its impact on ERCP-related outcomes requires investigation. This study evaluated the impact of frailty on ERCP-related adverse events. MethodsThe National Inpatient Sample from 2016 to 2019 was used to identify adult patients who underwent ERCP. Frailty was defined using the Frailty Risk Score. Outcomes were categorized into procedure-related adverse events, sedation-related adverse events, and hospitalization outcomes. Multivariate linear or logistic regression was used as appropriate. Stata, version 14.2, was used to perform analyses considering a 2-sided P < 0.05 to be statistically significant. ResultsAmong a total of 693,730 ERCPs performed, 870,30 (12.54%) were frail. Frail patients had higher odds of procedure-related adverse events, including hemorrhage (9.1/1000 vs 4.9/1000) and duodenal perforation, but not post-ERCP pancreatitis, bile duct perforation, cholecystitis, and cholangitis. Frailty imparted a higher risk of sedation-related respiratory failure, aspiration pneumonia, and the requirement of intubation and mechanical ventilation. Inpatient mortality was higher among frail patients (4.54% vs 1.03%), and they had prolonged hospital stays and higher hospitalization costs. ConclusionFrailty is associated with worse outcomes in patients undergoing ERCP, with higher risks of hemorrhage and sedation-related adverse events, in addition to increased resource utilization. Therefore, the findings of this study suggest strict adherence to guidelines governing anticoagulant management during the peri-endoscopic period, and sedative administration should be carefully monitored. Preprocedural optimization measures and diligent monitoring can minimize resource utilization and decrease periprocedural morbidity.

Spontaneous perforation in the bile duct system

Aim. To evaluate different therapeutic and diagnostic approaches in spontaneous bile duct perforation.Materials and methods. The present study involved the reports on spontaneous perforations in the bile duct system, published from 01.01.2000 to 01.06.2022 and selected by structured search in PubMed/Medline database.Results. As a result, 58 articles describing 71 patients were selected for the study. The most frequent symptoms of the disease included abdominal pain (92.9%), fever (39.4%), and jaundice (33%). The provisional diagnosis was made correctly in 52.1% of cases. The development of the disease was most often associated with choledocholithiasis (38%). Bile ducts perforation of the left hepatic lobe was revealed in 40.6% of cases, perforation of the common bile duct – in 35.5%. Bile duct perforation resulted in peritonitis in 42.2% of patients and bile accumulation or abscess in 30.9%. Encapsulated and intrahepatic accumulation of bile was found in 18.3% of cases. Management of perforations with development of encapsulated and intrahepatic bile accumulation included combined treatment, embracing percutaneous transhepatic drainage and endoscopic methods. Perforation of bile ducts with development of extensive forms of the disease required two-stage treatment. The first stage involved lavage of the abdominal cavity and decompression of the biliary tract. The second stage involved resective and reconstructive surgery to eliminate the cause of the perforation. The mortality rate was 5.6%.Conclusion. Spontaneous perforation in the bile duct system is a rare pathological state appeared as a complication of hepatopancreaticoduodenal diseases. Its management requires greater awareness of abdominal surgeons. The surgical strategy is based on correctly diagnosed and staged treatment tactics, which allows the incidence of complications and mortality rate to be reduced.

Spontaneous Retroperitoneal Biloma "Choleretroperitoneum" Complicating a Tumor of the Main Bile Duct: Exceptional Complication about a Case

Biloma refers to the accumulation of bile outside the biliary tract, which can be encapsulated or not. This condition is often caused by trauma, abdominal surgery, duodenal diverticula, or biliary disease. Spontaneous perforation of the common bile duct is rare in adults, and only a few cases have been reported in the literature. We present a case of spontaneous retroperitoneal biloma complicating a tumor of the main bile duct in a 77-year-old woman.

Spontaneous perforation of the common bile duct in a pediatric patient. Case report and short review of the literature

Spontaneous perforation of the common bile duct in a pediatric patient. Case report and short review of the literature

Spontaneous bile duct perforation causing biliary peritonitis in chronic pancreatitis

Spontaneous bile duct perforation causing biliary peritonitis in chronic pancreatitis

Validation of Tokyo guidelines 2018 for safety and mortality benefit from urgent ERCP in acute cholangitis across different age groups.

The 2018 Tokyo Guidelines (TG18) recommend urgent endoscopic biliary drainage based on acute cholangitis (AC) severity. Therefore, we evaluated the safety and mortality benefits of urgent endoscopic retrograde cholangiopancreatography (ERCP) in different age groups. Using International Classification of Diseases-10 (ICD-10) codes, we sampled adult AC patients from National Inpatient Sample. TG18 definition of cholangitis severity was used to identify patients with severe and nonsevere (mild or moderate) AC. Age categories were 18-64, 65-79, and 80 and above. Multivariate linear or logistic regression was used as appropriate. We used Stata, version 14.2, to perform analyses considering two-sided p< .05 as statistically significant. Among 137 100 patients, there were 93 365 (68.09%) patients with nonsevere cholangitis and 43 735 (31.91%) patients with severe cholangitis. Urgent ERCP (within 24 h) resulted in decreased mortality in all age groups for both severe and nonsevere AC. Post-sphincterotomy bleeding was more common in patients ≥80 years of age, whereas post-ERCP acute cholecystitis was more common in patients 65-79 years. The rates of post-ERCP pancreatitis, bile duct perforation, and duodenal perforation did not differ among the age groups. In addition, there were no differences in the rate of sedation-related complications between different age groups who underwent urgent ERCP. This study demonstrates the mortality benefit from urgent ERCP for AC in different age groups and describes the safety of performing urgent ERCP in patients of various ages. Therefore, we recommend that urgent ERCP be performed according to the TG18 guidelines regardless of age.

Clinical Outcomes of Percutaneous Biliary Endoscopy: A 7-Year Single-Institution Experience

PurposeTo evaluate safety and effectiveness of percutaneous biliary endoscopy (PBE) performed on patients ineligible for surgery or endoscopic retrograde cholangiopancreatography. Materials and MethodsRetrospective review was conducted for all patients who underwent PBE at a single academic institution between June 2013 and February 2020; 39 patients underwent 58 choledochoscopy sessions, and 21 patients underwent 48 cholecystoscopy sessions. Choledochoscopy indications included stone removal (23 of 39 patients) or biliary stenosis evaluation (19 of 39 patients). Cholecystoscopy indications included calculous cholecystitis (18 of 21 patients) and symptomatic cholelithiasis (3 of 21 patients). Technical success, procedural and fluoroscopy times, and tube-free survival were assessed. ResultsFor all PBEs performed for stone clearance, using disposable endoscopes led to shorter mean ± SD procedural (128.7 minutes ± 56.2 vs 240.2 minutes ± 184.6; P < .01) and fluoroscopy times (10.7 minutes ± 7.9 vs 16.5 minutes ± 12.0; P = .01) than using reusable endoscopes. Increasing institutional experience was associated with reduced procedural time (β = −56.73; P < .001). Choledochoscopy technical success was 94.8% with 1 adverse event of bile duct perforation with bile leak requiring drainage. For patients with choledocholithiasis, biliary drains were removed in 14 (60.9%) patients, with a mean tube-free survival of 22.1 months ± 23.8. For cholecystoscopy, technical success was 93.8% with no adverse events. Cholecystostomy tubes were removed in 15 (71.4%) patients, with a mean tube-free survival of 7.5 months ± 8.8. ConclusionsThis study supports PBE as a safe and feasible option for nonsurgical patients or those with altered anatomy precluding endoscopic retrograde cholangiopancreatography. Moreover, PBE may result in tube-free survival.

Clinical analysis of 45 cases of perforation were identified during endoscopic retrograde cholangiopancreatography procedure.

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important method to diagnose and treat biliary-pancreatic diseases. Perforations are infrequent but serious complications can occur during ERCPs. However, it is unclear which patients are suitable for surgery and when these patients should receive surgery. To analyze the outcome of 45 patients with endoscopic retrograde cholangiopancreatography (ERCP) related perforation. We retrospectively reviewed all 45 patients with ERCP-related perforation between January 2003 and December 2017, and observed the location and causes of perforation, treatment strategies, and mortality. Twenty thousand four hundred and seventy-nine patients received ERCP procedures from January 2003 to December 2017 in our digestive endoscopy center. Forty-five patients suffered from ERCP-related perforations. The incidence rate of ERCP-related perforations was 0.22%. Twenty-six patients suffered from periampullary perforations, 15 patients suffered from duodenal wall perforations, 1 patient suffered from a fundus perforation, 1 patient suffered from a residual gallbladder duct perforation, 1 patient suffered from a papillary diverticulum perforation, and 1 patient suffered from an intrahepatic bile duct perforation. Six patients with duodenal perforations underwent surgery, and the other patients received conservative treatment. One patient with a duodenal perforation and ERCP-related pancreatitis died of heart failure, and all the other patients recovered. The mortality rate was 2.2%. Endoscopic closure is seen as the first method for treating Stapfer type I perforations in the early phase, and surgery is seen as a remedial method when local treatment was failed. The Stapfer type II to type IV perforations can recover by conservative treatment.

S1070 Outcomes and Trends of Endoscopic Retrograde Cholangio-Pancreatography in Bariatric Surgery Patients - A National Inpatient Sample (NIS) Study

Introduction: Bariatric surgery (BS) is a widely used modality of treatment in patients with morbid obesity. The lifetime risk of these patients needing Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has increased. ERCP in this population is time-consuming and technically challenging due to altered anatomy. Despite several techniques, there are complications associated with each type of ERCP. Our aim was to assess trends and outcomes of ERCP in BS patients. Methods: We utilized the Nationwide Inpatient Sample (NIS) database from 2007 to 2018. We identified adult hospitalized patients who underwent ERCP using CPT procedure codes. These were divided based on the presence of bariatric surgery (BS) status and nonbariatric surgery (NBS). All procedures were captured using previously validated CPT codes, comorbidities were captured using previously validated ICD 9 and 10 codes. Univariate and multivariate logistic regression for categorical variables and linear regression for continuous variables was carried out to identify independent associations at p < 0.05. Statistical Analysis was performed using R studio. Results: Total 2,178,983 patients had ERCP between 2007 and 2018, from which 36,713 (1.7%) were performed in BS patients. Among the patients who received ERCP, 68% were females, 72% were Caucasians (Table). Rates of ERCP in BS patients increased from 1,593 (4.3%) in 2007 to 5075 (14%) in 2018 (p < 0.01). Total charges associated with BS was $76,902 vs $55,252 (p< 0.001). ERCP for Cholecdocholithiaisis (2.1% vs 1.4%) was more common in BS patients. On univariate analysis, bleeding, intra-abdominal infections, bile duct perforation, and inpatient mortality were statistically significant amongst BS patients as compared to NBS patients. On multivariate analysis, BS patients had higher risk of death (aOR: 1.38, 1.18-1.63) and bleeding complications (aOR: 1.73, 1.44-2.07) as compared to NBS patients. While acute pancreatitis was significantly higher in NBS patients as compared to BS patients. Acute cholangitis was comparable in BS and NBS patients (Table 2). Conclusion: The utilization of ERCP has been increasing over the last decade. The BS group had younger females and had higher utilization of health care resources. BS group despite being younger had a higher mortality rate and had more bleeding complications as compared to NBS. ERCP should be performed with caution in patients with BS to avoid mortality and worse inpatient outcomes. Table 1. - Demographics, indications of bariatric and nonbariatric surgery patients Non Bariatric Surgery Group (n = 2,142,270) Bariatric Surgery Group (n= 36,713) p-value AGE 62 (46, 76) 57 (44, 67) < 0.001 AGE GROUP < 0.001 18-27 116,840 (5.5%) 425 (1.2%) 28-37 343,200 (16%) 2,262 (6.2%) 38-47 391,922 (18%) 5,754 (16%) 48-57 387,558 (18%) 8,811 (24%) 58-67 313,532 (15%) 8,042 (22%) 68-77 216,827 (10%) 6,094 (17%) 78-87 197,928 (9.2%) 4,015 (11%) 88 and above 174,463 (8.1%) 1,311 (3.6%) GENDER < 0.001 Male 879,110 (41%) 11,618 (32%) Female 1,262,064 (59%) 25,080 (68%) Unknown 1,097 (< 0.1%) 15 (< 0.1%) RACE < 0.001 White 1,326,854 (68%) 24,424 (72%) African American 178,702 (9.1%) 3,558 (10%) Hispanic 305,630 (16%) 4,081 (12%) Asian/Pacific Islander 72,335 (3.7%) 852 (2.5%) Native American 13,664 (0.7%) 153 (0.4%) Other 66,140 (3.4%) 1,016 (3.0%) Unknown 178,946 (8.4%) 2,628 (7.2%) LENGTH OF STAY (Days) 4.0 (3.0, 7.0) 6.0 (3.0, 12.0) < 0.001 YEAR < 0.001 2007 157,405 (7.3%) 1,593 (4.3%) 2008 172,320 (8.0%) 1,829 (5.0%) 2009 170,895 (8.0%) 2,135 (5.8%) 2010 176,302 (8.2%) 2,661 (7.2%) 2011 179,012 (8.4%) 2,440 (6.6%) 2012 168,425 (7.9%) 2,500 (6.8%) 2013 167,540 (7.8%) 2,540 (6.9%) 2014 168,515 (7.9%) 3,145 (8.6%) 2015 174,610 (8.2%) 3,440 (9.4%) 2016 200,030 (9.3%) 4,595 (13%) 2017 201,935 (9.4%) 4,760 (13%) 2018 205,280 (9.6%) 5,075 (14%) OBESITY 309,544 (14%) 11,259 (31%) < 0.001 TOTAL CHARGES ($) $55,252 (34,801, 87,258) $76,902 (46,432, 139,565) < 0.001 INDICATIONS FOR ERCP Acute Pancreatitis 14,015 (0.7%) 255 (0.7%) 0.7 Acute Cholangitis 124,546 (5.8%) 1,498 (4.1%) < 0.001 Choledocholithiasis 30,785 (1.4%) 765 (2.1%) < 0.001 Pancreatic Cancer 25,946 (1.2%) 460 (1.3%) 0.7 Hilar Cholangiocarcinoma 20,022 (0.9%) 278 (0.8%) 0.12 Table 2: - Multivariate Logistic Regression of ERCP Complications and Inpatient Mortality Adjusted Odds Ratio 95% CI p-value Inpatient Mortality 1.75 1.49-2.07 < 0.01 Acute Pancreatitis 0.36 0.15-0.86 0.02 Acute Cholangitis 1 0.92-1.11 0.84 Bleeding 2.05 1.71-2.45 < 0.01 Cholecystitis 1.18 0.79-1.77 0.42 Intraabdominal Infections 4.12 3.33-5.11 < 0.01 Bile Duct Perforation 3.77 3.07-4.63 < 0.01

Outcomes of Hospitalized Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) With and Without a History of Peripheral Artery Disease.

IntroductionPeripheral artery disease (PAD) is a common illness associated with an increased risk of complications and mortality. Gastroenterologists considering endoscopic retrograde cholangiopancreatography (ERCP) in these patients should weigh the benefits and risks carefully. Our goal is to analyze the hospital burden and complication rates in patients with PAD undergoing ERCP.MethodsUsing data from the National Inpatient Sample (NIS), patients over the age of 18 with and without PAD undergoing ERCP were identified utilizing the International Classification of Diseases (ICD)-9 codes. Primary outcomes included inpatient mortality, length of stay, and hospital charges. Secondary outcomes included rates of bile duct perforation, post-ERCP bleeding, acute pancreatitis, and cholangitis. Supplemental data, including household income and primary payer, were also analyzed. Independent t-tests were used for continuous data, chi-square tests for categorical data, and confounding variables (diabetes, age, gender, race) were controlled via multiple logistic regression.ResultsMost of the PAD group were male, while those in the non-PAD group were female (adjusted p<0.05). Mortality was higher in the PAD group (11.2% versus 8%; adjusted p<0.05). Members of the PAD group had longer lengths of stay (11.6 days versus 11 days; adjusted p<0.05) and more costly hospital stays ($108,006.49 versus $94,399.09; p<0.05). Members of the PAD group had higher rates of post-ERCP bleeding (5.2% versus 3.7%; adjusted p<0.05) and lower rates of cholangitis (6% versus 4%; adjusted p<0.05) and acute pancreatitis (6.9% versus 3.4%; adjusted p<0.05). ConclusionPatients with PAD had an increased hospital burden but had a decreased risk of post-ERCP complications, including cholangitis and pancreatitis. Physicians performing risk stratification for patients with PAD undergoing ERCP must consider these specific complications and ensure that patients undergoing this procedure are fully aware of the dangers and benefits of ERCP prior to consenting to the procedure.

Acute abdomen with jaundice: A clue to extrahepatic biliary tract perforation.

IntroductionAmong a plethora of causes of acute abdomen, spontaneous common bile duct perforation (SCBDP) resulting in biliary peritonitis is almost never envisaged. Since the term SCBDP is often misconstrued as absence of an identifiable cause of perforation, ‘nontraumatic perforation of CBD’ is also in parlance to exclude relatively common causes such as trauma and iatrogenic injuries. In adults, choledochal cyst, cholangitis, infection, pancreatitis, pancreatobiliary maljunction have been identified as causes of perforation, however, choledocholithiasis remains the most common cause associated with spontaneous perforation of extra hepatic bile duct.Case presentationHere we present three cases of a spontaneous common bile duct perforation that presented as acute abdomen with peritonitis. Clinical presentation, biochemical abnormalities, imaging details, treatment options, and outcome were studied. This study has been reported in line with the SCARE 2020 Guideline [1].Discussion and conclusionSpontaneous perforation of the extrahepatic bile duct is a rare but important presentation of gallstones in adults and needs a high index of suspicion during day-to-day practice. Surgeons should seek out this uncommon diagnosis in the patient for early surgical intervention and appropriate drainage to ensure survival.

Spontaneous common bile duct perforation presenting as extrahepatic bilioma: a rare clinical presentation of gall stone disease

Spontaneous common bile duct perforation presenting as extrahepatic bilioma: a rare clinical presentation of gall stone disease

Spontaneous perforation of common hepatic duct: an intraoperative surprise

BackgroundPediatric spontaneous bile duct perforation is one of the rare causes of acute abdomen in infants. With a highly variable presentation, diagnosis and treatment can prove challenging. We report a case of spontaneous common hepatic duct perforation mistaken for appendicular peritonitis.Case presentationAn otherwise healthy 3-year-old boy presented to the emergency department with complaints of abdominal pain, distention, bilious vomiting, and fever evolving for 4 days. Preoperative ultrasound was suggestive of appendicular peritonitis. Laparotomy revealed abundant biliary fluid, a distended gallbladder with thickened and inflammatory wall, and a macroscopically normal appendix. Intraoperative cholangiography showed a leak of contrast from the anterior wall of the common hepatic duct, 2–3 mm below the upper biliary confluence and 2 cm above the junction of the cystic duct to the common hepatic duct. A cholecystostomy was performed, and two external intraabdominal drains were placed. A retrograde cholangiogram was performed on postoperative day 21 showing no extravasation of contrast product. The patient was discharged on postoperative day 25.ConclusionSpontaneous perforation of the common hepatic duct is a rare phenomenon. It should be considered as a differential diagnosis in pediatric patients that present with unexplained peritonitis. The optimal method of diagnosis and management remains controversial.

Analysis of the Clinical Characteristics of Spontaneous Bile Duct Perforation in Children.

ObjectiveThis study aimed to explore the etiology, clinical features, diagnosis, and treatment of spontaneous bile duct perforation (SBDP) in children.MethodsThe clinical data of children with SBDP who were admitted to Wuhan Children's Hospital between January 2014 and January 2020 were retrospectively analyzed.ResultsIn all, 28 cases of children with SBDP (male, 28.6%; female, 71.4%; male-to-female ratio, 1:2.5; average age, 2.15 years) were analyzed. The most common symptoms were fever (85.7%), nausea and vomiting (78.6%), and abdominal distension (67.9%). Among the 28 patients, 26 (92.9%) had elevated hypersensitive C-reactive protein, 24 (85.7%) had an increased neutrophil percentage, and 22 (78.6%) had raised peripheral blood leukocyte counts. Moreover, 19 patients (67.9%) showed increased serum total bilirubin levels, and 5 (17.9%) showed an elevated conjugated bilirubin level. Abdominal CT examination revealed that the gallbladder wall of patients was thickened with edema, accompanied by gallbladder stenosis and gallbladder mucosa enhancement; furthermore, ascites was found in the abdominal cavity and lesser omental bursa. Twenty-two patients underwent abdominal paracentesis, and 20 (90.9%) of them were exposed to bile-based ascites. Among the 28 patients, four recovered with conservative treatment, whereas the others (85.7%) were surgically treated. Of the twenty-four patients undergoing surgery, the perforation site was found at the union of the hepatic and cystic ducts in 12 patients (50%), no perforation site was observed in 9 patients (37.5%), and a common hepatic duct was observed in 3 patients (12.5%). All 24 patients underwent stage I surgery, and temporary biliary drainage was performed because of severe abdominal inflammation. Cholangiography and enhanced CT revealed an abnormal location of the pancreatic duct joining the bile duct in 64.3% patients. Following surgery, 15 patients underwent hepaticojejunostomy. Subsequently, 3-month to 6-year follow-up (median, 30 months) indicated that the patients recovered well with no serious complications.ConclusionSBDP in children may be associated with pancreaticobiliary malunion (PBM) and congenital weakness of the bile duct wall. However, the clinical manifestations of this condition lack specificity; this limitation can be assisted through diagnosis via abdominal CT and by performing abdominal paracentesis. Once SBDP diagnosis is confirmed, the patient should follow the principles of individualized treatment.

A comparison of balloon- versus stent-based approach for dominant strictures in primary sclerosing cholangitis: a meta-analysis.

BackgroundApproximately 10-62% of patients with primary sclerosing cholangitis (PSC) will develop dominant strictures at some point during their disease. Because of the paucity of available data, optimal endoscopic therapeutic strategies remain unclear. We performed a systematic review and meta-analysis of endoscopic balloon dilation vs. balloon dilation plus stenting of dominant strictures in PSC.MethodsA comprehensive literature search from inception to November 2020 was performed. Primary outcomes were clinical and technical success. Secondary outcomes reported were adverse events (AE). Clinical success was defined in most studies as improvement in symptoms such as fever, abdominal pain, pruritus, fatigue and/or liver enzymes. The statistical analysis was done using comprehensive meta-analysis (CMA Version 3).ResultsThe technical success rates for balloon and balloon plus stent were 96.8% and 91.9%, respectively. The clinical success rates for balloon and balloon plus stent were 86.5% and 70.8%, respectively. The overall AE rates for balloon and balloon plus stent were 11.2% and 26.9%, respectively. Other AE rates in balloon and balloon plus stent were cholangitis (4.8% vs. 11.4%), bile duct perforation (1.3% vs. 1.6%), post-procedural pancreatitis (2.2% vs. 9.8%), and bleeding (1.5% vs. 1.2%), respectively. Low to considerable heterogeneity was noted in our meta-analysis.ConclusionsBalloon dilation appears to be superior in terms of clinical and technical successes, with overall lower rates of AE compared to balloon dilation plus stenting for the management of PSC dominant strictures. Further trials are needed to validate our findings.

750 An Unusual Presentation of a Rare Clinical Entity – A Case Report of Spontaneous Common Bile Duct Perforation in an Adult

Abstract Spontaneous or non-traumatic perforation of the extrahepatic biliary system is a rare clinical phenomenon, with few cases reported since its first mention in medical literature by Freeland in 1882. Given the rarity, misdiagnosis is common with the diagnosis almost always made during urgent exploratory laparotomy. We describe a case of spontaneous common bile duct (CBD) perforation in an 83-year-old female with no associative underlying disease process identified. The patient presented with sudden onset abdominal pain with no identifiable trigger, with minimal past medical history. Examination was remarkable for findings of epigastric tenderness and guarding. Haematological investigation was remarkable only for hyperamylasaemia and leucocytosis. Pneumoperitoneum was ruled out and following contrast CT abdomen and pelvis a working diagnosis of mild pancreatitis was made. US Abdomen and MRCP found no evidence of cholelithiasis, with minimal biliary duct dilatation. The patient continued to deteriorate on the ward, with aspiration of new intrabdominal fluid collection raising suspicion of perforated viscus. Exploratory laparotomy revealed a 1-cm defect in the CBD with frank bile leak. A T-tube was placed in the common bile duct defect, with an abdominal robertson drain also inserted. No further bile leak was identified via Tubogram, with the patient successfully discharged following multidisciplinary rehabilitation in intensive care and the ward setting. Surgeons should seek out this uncommon diagnosis in patients with hyperamylasaemia and suspected cholelithiasis who do not conform to normal biliary/pancreatic disease progression patterns.