Biliary Perforation Research Articles

Spontaneous Perforation of the Bile Duct in Infancy and Childhood: A Systematic Review

CASE 1 A 3-month-old boy presented with a history of jaundice, abdominal distension, vomiting, pale stools, and failure to thrive. On examination, the child was jaundiced but not unwell. The abdomen was distended with the presence of massive ascites. Bilateral hydroceles were evident. Serum liver enzymes were within normal limits. Plain abdominal film showed a ground glass appearance. Abdominal ultrasound scan (USS) showed normal liver and gallbladder with no dilatation of the intrahepatic bile ducts. No mass was detected. Radionuclide scanning demonstrated prompt visualisation of the liver and gallbladder, followed by visualisation of the CBD that looked slightly dilated. The tracer was found to be leaking into the peritoneal cavity, and there was no tracer in the intestines even at 24 hours (Fig. 1). Ascitic aspiration revealed yellow-coloured fluid. With the diagnosis of spontaneous biliary perforation in mind, a laparotomy was performed. There was a thinwalled pseudocyst at the porta hepatis. Intraoperative cholangiogram through the gallbladder showed extravasation of contrast from the CBD. A small perforation was found on the anterior wall of the CBD at the junction with the cystic duct. There was no distal obstruction. A cholecystectomy was performed and a size 8F T tube was placed into the perforation and the perforation closed around this. An external drain was left in the area of the pseudocyst. The T tube was removed once it had stopped draining and the external drained removed 2 days later. This patient was alive and well 1 year postoperatively.

Erosion and perforation of the biliary tree by plastic biliary endoprostheses

Biliary endoprostheses are increasingly used in the treatment of both benign and malignant pancreaticobiliary disorders. Common bile duct stones are a common clinical problem for which there now exist a range of treatment modalities. Official guidelines in the UK advocate the use of plastic biliary endoprostheses in the treatment of common bile duct stones only as a short-term measure prior to definitive endoscopic or surgical clearance. Long-term use of such stents is associated with several complications related to stent insertion, occlusion, and migration. Organ perforation resulting from plastic biliary stents is very rare and can occur either as an early complication at stent insertion or as a late complication resulting from stent migration and pressure necrosis. Although duodenal, small-bowel, and colonic perforations have been described, we have found no reports of extra-hepatic bile duct perforation occurring as a complication of plastic biliary stents. We present three cases of biliary tree erosion and perforation by plastic stents placed in patients with common bile duct stones cleared endoscopically prior to laparoscopic cholecystectomy and discuss the possible implications of this previously unreported phenomenon.

Management of biliary perforation in children

To study the aetiology, management and outcome of biliary perforations in paediatric age group. In a retrospective study, the records of patients presented with biliary peritonitis due to biliary perforations, managed from March 2006 to July 2009, are reviewed. Eight male patients with biliary peritonitis due to biliary perforation were managed. These patients were divided in two groups, A and B. Group A, (n = 3) patients, had common bile duct (CBD) perforation, and Group B (n=5) patients had gallbladder perforation. The presenting features were abdominal pain, fever, abdominal distension, vomiting, constipation, jaundice and signs of peritonism. The management of CBD perforations in Group A was by draining the site of perforation and biliary diversion (tube cholecystostomy). In Group B, the gallbladder perforations were managed by tube cholecystostomy in four patients and cholecystectomy in one patient, however, one patient had to be re-explored and cholecystectomy performed due to complete necrosis of gall bladder. There was no mortality in our series. All patients were asymptomatic on regular follow-up. Early optimal management of biliary perforations remarkably improved the very high mortality and morbidity that characterised this condition in the past.

Choledochoscopic laser fithotripsy for refractory residual biliary calculi after surgery

Objective To explore the efficacy and safety of choledochoscopy combined with laser lithotripsy for refractory residual biliary calculi after operation. Methods Clinical data of 22 patients, who underwent choledochoscopy together with laser lithotripsy for refractory intra- and extra-hepatic calculi after operation from February 2007 to February 2009, were retrospectively studied. Results The success rate of stone removal was 95.5% （21/22）, with one session success rate of 86.4% （19/22）, and two sessions of 9. 1% （2/22）. Stone removal could not be performed in one patient due to multiple intra-hepatic calculi, difficult calculi location at bile ducts of grade Ⅱ, and wide biliary angle with no access. No biliary duct hemorrhage, perforation, or infection occurred. Conclusion Choledochoscopy combined with laser lithotripsy is an effective and safe procedure for refractory residual biliary calculi after operation. Key words: Choledochoscope ; Lithotripsy, laser; Calculi ; Refractory

Utility of ERCP in Neonatal and Infant Cholestasis

In neonates and infants with biliary obstruction, the diagnosis is important to establish early. Despite the use of several noninvasive imaging modalities, a definite diagnosis of biliary atresia (BA) or other pancreaticobiliary disorders may be difficult to ascertain. In this paper, we report our experience with endoscopic retrograde cholangiopancreaticography (ERCP) in the clinical situation of neonatal and infant jaundice. Between 1999 and 2006, we performed 23 ERCP procedures in 22 neonates and infants with the provisional diagnosis of biliary obstruction where other imaging was inconclusive. The mean age was 2.4 months and the mean weight was 4.8 kg. A pediatric videoendoscope with an outer diameter of 7.5 mm was used in all patients. ERCP was successful in 20 of 23 patients. BA was suggested in 6 patients, all subsequently verified by surgery. Detailed visualization of biliary structures important for planning of treatment was performed in children with choledochal cysts and spontaneous biliary perforation. Cannulation of the ampulla failed in 3 patients, of whom 1 had BA, 1 a choledochal stone, and 1 bile plug syndrome. Only 1 therapeutic ERCP was performed in a child with a stone completely obstructing the ampulla. The only complications were 1 asymptomatic case of hyperamylasemia and 1 of mild cholangitis successfully treated with antibiotics. ERCP is feasible and safe in the workup of neonatal cholestasis where other imaging modalities are inconclusive. Despite the expanding role of magnetic resonance cholangiography, ERCP may still have a role in the multidisciplinary workup of these patients.

Pneumoperitoneum caused by gastroscopy in a jaundiced patient treated endoscopically after initial percutaneous approach

A 78-year-old man with neoplastic obstructive jaundice, who had undergone placement of a percutaneous drainage catheter (10-Fr internal/external catheter), was admitted for endoscopic retrograde cholangiopancreatography (ERCP). The cholangiogram revealed an irregular stricture of the distal common bile duct. A hydrophilic guide wire was inserted across the transhepatic drainage and recovered endoscopically; we removed the percutaneous drain, performed a biliary sphincterotomy, and inserted an 8-cm Zilver metallic stent (Wilson-Cook Medical Inc., Winston-Salem, North Carolina, USA). Three days after ERCP, the patient underwent esophagogastroduodenoscopy with duodenal biopsies taken for histological analysis; the latter identified an adenocarcinoma. Immediately after esophagogastroduodenoscopy the patient developed acute abdominal pain. A CT scan ([Fig. 1]) revealed free air in the abdomen and ascites around the spleen, in the right laterocolic space, and among the jejunal loops. The patient underwent urgent laparotomy but no bowel or biliary perforation was revealed. Intraoperative cholangiography showed correct working of the biliary stent, but free passage of contrast medium was observed through a fistula where the percutaneous drain had previously been. A cholecystectomy was performed and a T tube left in place. The postoperative course was normal. It would appear that air inflation during the esophagogastroduodenoscopy had facilitated the passage of air from the duodenum to the peritoneum across the fistula created by the percutaneous drain; the ascitic liquid, leaving a distance between the hepatic surface and the abdominal wall, made development of the pneumoperitoneum even easier, because of the incomplete consolidation of the biliocutaneous fistula.

Spontaneous Biliary Perforation in an Infant: An Unusual Chronic Presentation

Spontaneous perforation of the biliary ducts is a rare disorder in infants. Early diagnosis of this entity is important because it can be treated surgically. We report on a 4-month-old child presenting with jaundice and progressive abdominal distention present since birth. Hepatobiliary scintigraphy, which was done to rule out any obstructive pathology, showed a biliary leak from the porta hepatis region leading to biliary ascites and bilateral hydroceles. Surgical exploration and intraoperative cholangiogram confirmed cystic duct perforation. Cholecystectomy and inguinal herniorrhaphy were performed. Follow-up hepatobiliary scintigraphy demonstrated complete resolution of the bile leak and hydroceles.

Choledochal cysts in infancy and childhood

To study the clinical presentation, management and results of treatment of 41 consecutive cases of choledochal cyst (CC) managed from 1999 to 2006. The age of the patients ranged from 20 days to 11 years. Eleven cases were 1 year or less in age (infantile group) and 30 patients were more than 1 year old (classical pediatric group). Children less than 1 year old presented with jaundice (72%), hepatomegaly (54%) and clay-colored stools (63%); whereas those above one year in age presented with pain (83.3%) and jaundice (47.6%). Three cases had biliary perforation with localized or generalized biliary peritonitis. Ultrasonography (US) diagnosed/suggested CC in all 41 patients, however, contrast-enhanced computed tomographic (CECT) scan (n=12), radionuclide DISIDA scan (n=5) and magnetic resonance cholangiopancreatogram (MRCP) (n=3) also contributed to the diagnosis. 19 patients, including 4 from the 'infantile' group, had significant dilatation of intrahepatic biliary ducts. Nine patients from the 'infantile' group had cystic type I CC (type Ic), while 2 patients had fusiform dilatation of the common bile duct (type If disease). In contrast, 21 of the older patients had type If disease while 9 had type Ic disease. Operative management included primary complete excision of the cyst with a Roux-en-Y hepaticodochojejunostomy (HDJ) (n=32), Lilly's modification of submucosal resection with a HDJ (n=8) and cyst excision with a hepaticodochoduodenostomy (HDD) (n=1). All 3 patients with biliary perforation had primary excision of the CC with a HDJ. Unusual operative findings included accessory hepatic ducts (n=2), anteriorly placed common or right hepatic arteries (n=3) and partially or completely blocked proximal extrahepatic bile ducts (n=3). There were 2 postoperative deaths, one had cirrhotic liver disease with portal hypertension, the other had deep icterus with poor general condition. Both patients succumbed to overwhelming sepsis. One patient required reexploration and refashioning of the HDJ for biliary leak. Short-term follow-up was satisfactory in all 39 patients. Infants with CC constitute a distinct group with regard to clinical presentation and the pathological should be kept in mind while evaluating neonates and infants with cholestatic jaundice and older children with recurrent abdominal pain. Primary excision of the cyst with a HDJ provides satisfactory results in the management of the vast majority of cases of CC including those in infants, massive CC and in the presence of biliary perforation and peritonitis.

Spontaneous perforation of the biliary tract and portal vein thrombosis in infancy

Spontaneous biliary perforation (SBP) is an uncommon cause of surgical jaundice in the first few weeks of life and is characterised by the occurrence of a punched-out defect in the bile duct, typically where the cystic duct joins the common hepatic duct. In most cases the site occurs anteriorly and bile leaks into the general peritoneal cavity. We now describe two cases of SBP where the perforation occurred posteriorly, limiting the leak and resulting in delayed recognition. Surgical management in both cases consisted of hepaticojejunostomy-en-Roux. Both cases were complicated, although not immediately, by portal vein thrombosis and one by chylous ascites. Posterior SBP, presumably due to their intimate anatomical relation with the portal vein, seem predisposed to such complications.

Pancreaticobiliary and Duodenal Perforations After Periampullary Endoscopic Procedures

To review our experience with management of pancreaticobiliary and duodenal (PB/D) perforations after periampullary endoscopic interventions. Although pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures are rare, their management has not been well described. Individuals who experienced pancreaticobiliary and duodenal perforations. Comorbidities, interventions performed, mechanism/site of perforation, management, and hospital morbidity/mortality. Seventy-five perforations (0.6%) occurred in 12,427 procedures; 20 perforations (27%) occurred during biliary stricture dilatation, 18 (24%) during diagnostic endoscopic retrograde cholangiopancreatography, and 15 (20%) during management of choledocholithiasis. Perforations were caused by guidewire insertion in 24 patients (32%), sphincterotomy in 11 (15%), passage of the endoscope in 8 (11%), or stent migration in 7 (9%) and were identified during the index procedure in 45 patients (60%). Delayed presentations included pain in 33 patients (44%), leukocytosis in 26 (35%), and/or fever in 13 (17%) and were diagnosed using computed tomography in 19 patients (25%) and abdominal radiography in 10 (13%); 9 cases (12%) were diagnosed more than 24 hours after the procedure. Indications for operative treatment were gaping duodenal perforations and perforations in patients with surgically altered anatomy. Indications for nonoperative management included contained bile duct perforations and focal duodenal perforations. Management was nonoperative in 53 patients (71%) and operative in 22 (29%). Patients with duodenal perforations, higher American Society of Anesthesia status (P<.01 each), and older age (mean +/- SEM, 65 +/- 4 vs 55 +/- 2 years; P = .02) were more likely to require operative management. Hospital stay (mean +/- SEM, 16 +/- 4 vs 4 +/- 1 days; P<.05) and mortality (13% vs 4%; P<.05) were greater in operative patients (P<.05 each). Most (70%) pancreaticobiliary and duodenal perforations secondary to periampullary endoscopic interventions can be managed nonoperatively. Most biliary perforations can be managed nonoperatively; a requirement for operative treatment increases the mortality rate.

Spontaneous biliary perforation in infancy and childhood: Clues to diagnosis

Spontaneous perforation of extrahepatic bile duct is rare. The cause is idiopathic once trauma and choledochal cyst are ruled out. The condition presents a diagnostic dilemma. Preoperative recognition is necessary as early surgical intervention gives excellent prognosis. We report clinical observations made in three cases with acute presentations. Diagnosis is to be suspected by the presence of jaundice after an initial anicteric period of good health with biliary ascites. This is confirmed by bilious abdominal paracentesis, signs of peritonitis and absent free gas on X ray. The constellation of these three findings was constant in three patients. The presented paper highlights the same as reliable clues to diagnosis.

Idiopathic biliary perforation in a 10-year-old boy

A 10-year-old boy of African origin with AIDS and Stage IV Hodgkin's lymphoma presented with a short history of abdominal distension and bile ascites shown to be due to a perforation of his common bile duct. This was treated initially by laparotomy, external peritoneal drainage and endoscopic biliary stenting although without success. He then underwent a laparotomy and biliary diversion (Roux-en-Y hepaticojejunostomy) with satisfactory resolution of his bile duct pathology. Although the co-morbid conditions are likely to be contributory factors, biliary perforation in either disease has not been reported before.

Migration of Endoscopic Biliary Stent and Small Bowel Perforation Within an Incisional Hernia

Long-term complications from biliary stents, such as migration and perforation, are unusual but may occur. Distal perforations most commonly involve the colon or distal ileum. This report describes the case of a perforated small bowel, secondary to a stent trapped within an incisional hernia. Patients with comorbid abdominal pathologies, including colonic diverticulae or abdominal herniae, may be at increased risk of perforation from migrated stents.

Spontaneous common bile duct rupture in pregnancy

This report describes how a rare condition in pregnancy can present with features resembling more common diagnoses in the unwell obstetric patient. Our patient presented in late pregnancy initially with clinical features similar to mild preeclampsia, with proteinuric hypertension, epigastric pain and mildly deranged liver function tests. She went on to develop signs of acute abdomen associated with a persistent tachycardia and hypotension; there was evidence of fetal compromise. Following resuscitation, emergency caesarean section was performed and evolved into a laparotomy. The diagnosis was not clear clinically at this stage, but a retrospective amylase sample suggested acute pancreatitis. There was no clinical evidence of biliary perforation, but ongoing clinical suspicion prompted a CT of the abdomen. This proved unhelpful and our diagnostic dilemma was only resolved by endoscopic retrograde cholangiopancreatography, which demonstrated a biliary leak. A stent was placed with subsequent improvement in the patient's condition. With anaesthetists increasingly involved in the multi-disciplinary management of acutely sick obstetric patients, our case highlights the need for every practitioner involved in such cases to assess each individual fully, and be constantly aware that the diagnosis might not be obvious.

P-56 Idiopatic biliary perforation in an extremely low birth weight infant

P-56 Idiopatic biliary perforation in an extremely low birth weight infant

A mass in the omental bursa secondary to biliary leakage: identification and management

The local rather than diffuse biliary accumulation secondary to biliary leakage is a rare condition. Recently, we found a mass in the omental bursa secondary to biliary leakage in a 3-year-old girl. This girl was hospitalized for a choledochal cyst, which was shown by routine ultrasound examination, with no evidence of jaundice or abdominal pain. Laboratory values of hepatic function included the following: AKP, 57 U/l; SGOT, 8 U/l; total bilirubin, 13.5lmol/l. Cyst excision and cholecystectomy combined with Roux-en-Y hepaticojejunostomy were performed, and the peritoneal drainage was placed under the hepaticoduodenal ligament, as was routine. On the first day after the operation, 80 ml of bile-stained liquid was drained off. But there was no further drainage, even though some efforts were made to adjust the position of the drainage tube. Three days later, the patient began vomiting repeatedly after drinking, and a huge mass located between the stomach and the pancreas was demonstrated by computed tomography (CT) (Fig. 1). Laparotomy verified a mass in the omental bursa consisting of 500 ml of bilious liquid. No site of biliary or anastomotic leakage could be identified. Four drainage tubes were placed in the omental bursa and the peritoneal and pelvic cavities. The amount of drainage was 100 ml on the first postoperative day. This amount decreased day by day, and the drainage tubes were discontinued on the 10th postoperative day. The patient is doing well 3 months postoperatively. Spontaneous biliary perforation and anastomotic leakage are the most common causes of biliary leakage in children [1]. The amount of bile that accumulates in the peritoneal cavity in a short time secondary to biliary leakage may lead to peritonitis. However, insidious rather than acute presentation of biliary leakage is more common in children, and is usually characterized by progressive jaundice, painless abdominal distension, ascites, and clay-colored stools [1]. Because of the chronic course, the inflammatory reaction might take place at the leakage site, and the inflammatory oozing might cover the leakage. Therefore, it can be difficult to determine the orifice of leakage in children. Some authors recommend performing a cholangiogram to locate the site of injury and obstruction. Others prefer hepatobiliary scintigraphy, either by 99m Tc-diethyl-iodine-HIDA or 99m Tc-diisopropyl-HIDA, to detect biliary leakage [2]. Recently, three-dimensional cholangio-spiral CT demonstrating the bile leak has been reported [3]. But the role of these diagnostic means to help deal with biliary leakage in children might be overestimated. Even if the biliary leakage can be detected, it is not always practical to

Spontaneous Biliary Perforation: Biloma Resembling a Small Bowel Duplication Cyst

Spontaneous Biliary Perforation: Biloma Resembling a Small Bowel Duplication Cyst

Endoscopic retrograde cholangiopancreatography in elderly patients.

the presentation of common bile duct disease, value of investigations and treatment outcome in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were assessed. the clinical presentation, liver function tests, full blood counts, abdominal ultrasound and ERCP results were assessed retrospectively in 101 patients (59 women, 42 men; mean age 83 years, range 75-100) sequentially investigated for possible common bile duct disease. 59 patients had common bile duct gallstones, 35 had malignant biliary obstruction (13 with co-existing common bile duct stones) and seven had other outcomes. In the malignant-alone group 68% of those who had jaundice presented painlessly compared with 24% in the gallstones-alone group; 49% of the gallstones-alone group had pain compared with 28% of the malignant group. In the gallstones-alone group 43% had atypical presentations (non-specific symptoms or painless jaundice). Non-specific symptoms were found in 19% of the gallstones-alone group but in only 5% of the malignant group. Of the patients who had common bile duct stones, 18% had pancreatic or biliary malignancy. The co-existence of gallstones and malignancy was emphasized by eight patients in whom the clinical and ultrasound diagnosis was of common bile duct stones but malignancy was detected by ERCP. The sensitivity of ultrasound was 86% for detecting dilated common bile ducts was 86%, but only 69% for diagnosing gallstones within the common bile duct and 67% for diagnosing pancreatic masses. Ultrasound and ERCP were in agreement in 60 patients (60%). Endoscopic clearance of common bile duct gallstones was successful in 53 of 54 attempts (98%). Palliative ERCP treatment was performed in 30 patients who had malignant biliary obstruction and was successful in 22 (73%); in a further four patients (13%) an endoprothesis was successfully inserted percutaneously. The commonest complication of ERCP was cholangitis (four patients); pancreatitis and biliary perforation occurred in one patient each. Twenty-two patients (63%) who had malignancy died during follow-up, the mean survival being 11.3 weeks (range 3 days-2 years). Carcinoma of the ampulla was associated with a relatively good prognosis (three patients survived 18 months or more). in elderly patients, common bile duct stones often present atypically and co-existence with malignancy is not unusual; ampullary carcinoma has a relatively good prognosis and ERCP is a safe and effective procedure in the management of biliary obstruction.

Surgical treatment of choledochal cysts in children

Choledochal cyst is often associated with pancreatobiliary malunion, and pancreatic juice usually refluxes into the bile duct via the malunion. Various pathological conditions develop in the biliary tract, pancreas, and liver: cholangitis, biliary dilatation, biliary perforation, biliary cancer, acute pancreatitis, and/or biliary cirrhosis. The performance of cystenterostomy has recently been abandoned because of high morbidity after surgery. Accurate delineation of the biliary tree and the pancreatobiliary junction obtained by endoscopic retrograde cholangiopancreatography or operative cholangiography is necessary. Cyst excision should be performed to prevent ascending cholangitis and biliary cancer. Many types of procedures are employed in biliary reconstruction, but free drainage of bile is imperative for preventing cholangitis and stone formation. This can be achieved only by a wide anastomosis performed at the hilum after ductoplasty.

Spontaneous biliary perforation: Does external drainage constitute adequate therapy?

Spontaneous perforation of the biliary tract in infancy is rare; fewer than 100 cases have been reported. The authours report on two patients with spontaneous biliary perforation (SBP) who were treated during the past 5 years. One of the patients, a 10-month-old boy, presented with an extensive retroperitoneal mass, without jaundice. He was found to have a perforation in the pancreatic portion of the common bile duct (CBD). The second patient, a 6-week-old boy, had insidious onset of jaundice, abdominal distension, and acholic stools. He was found to have a perforation at the cystic duct/CBD junction and distal CBD stricture. Both patients initially underwent cholecystostomy and drainage. The second patient had a persistent external biliary fistula and high-grade stricture, and subsequently underwent CBD excision and Roux-en-Y hepaticojejunostomy, at age 12 weeks. The authors' findings do not support the widely held concepts proposing that (1) the diminished distal ductal caliber often associated with these lesions occurs secondary to the perforation rather than is a primary causative factor and (2) the distal biliary obstruction does not require treatment because it resolves with adequate drainage. In the absence of ductal abnormalities, the authors advocate external drainage. For SBP associated with an underlying stricture, prompt biliary intestinal bypass is necessary to avoid biliary cirrhosis and portal hypertension.