Spontaneous Biliary Perforation Research Articles

Laparoscopic Management of a Rare Case of Spontaneous Biliary Perforation in an Infant

ABSTRACT Spontaneous biliary perforation is a rare condition, predominantly observed in infants, characterized by the leakage of bile into the peritoneal cavity without any apparent cause. This case report discusses a 3-month-old female infant who presented with symptoms of jaundice and abdominal distension. The successful management of this case with a combination of ultrasound-guided percutaneous drainage and laparoscopic cholecystostomy is detailed, highlighting the importance of minimally invasive techniques in treating this condition.

Spontaneous biliary perforation in a child: case report and review

Spontaneous perforation of the external biliary tract is an extremely rare pathology in childhood, presented in the literature by description of clinical cases. To date, a unified approach to the treatment of children with this pathology has not been developed.
 The paper presents a clinical case of spontaneous perforation of the anterior wall of the common hepatic duct in a child of seven months, with the development of bilioperitoneum against the background of obstruction of the common bile duct by bilirubin calculi.
 CASE REPORT. The disease began acutely with repeated vomiting, stool acholia, dark urine, and an increase in the size of the abdomen in a 7-month-old child. Examination in the hospital revealed ascites, cholecystitis and shadows of calculi in the projection of the hepatoduodenal ligament. According to the results of laparocentesis, bilioperitoneum was noted. The patient underwent laparotomy, 300 ml of serous-biliary effusion was removed from the abdominal cavity. On the anterior semicircle of the common hepatic duct there is a defect from which bile flows. Suturing of the perforation of the biliary tree, cholecystectomy and drainage of the external bile ducts through the stump of the cystic duct were performed. The cholangiostomy was removed after 1.5 months. Follow-up 1 year and 3 months, pathology is not determined during the examination.
 CONCLUSIONS. Sewing up the site of primary perforation with drainage of the external biliary tract can help accelerate the reparative process with a decrease in the risk of developing a biliary fistula. Performing primary reconstructive interventions on the abdominal cavity compromised by bilioperitoneum, in our opinion, is too risky.

Spontaneous bile duct perforation in a neonate

Abstract We present a case of spontaneous biliary perforation (SBP) in a previously healthy 3-week-old boy with worsening scleral icterus, abdominal distension, and acholic stools. Abdominal ultrasound demonstrated moderate ascites without extrahepatic ductal dilatation. The HIDA scan demonstrated accumulation of tracer within the right upper quadrant outside of the liver but not in the bowel, however there was a large amount of tracer activity seen diffusely within the abdomen that appeared to lie within the ascitic fluid and complicated the read of the scan. Intraoperative cholangiogram during an exploratory laparotomy confirmed an intact gallbladder with a mostly contained perforation at the junction of the cystic duct and the common bile duct with no contrast in the duodenum. The patient underwent an uneventful cholecystectomy with a Roux-en-Y hepaticojejunostomy and was discharged home three days later.

Spontaneous biliary perforation in a 3-month old

Abstract Spontaneous biliary perforation is a rare cause of jaundice in young children. A 3-month old girl presented to a referral facility with a history of jaundice and abdominal distension. Investigations suggested a hepatic cyst but on exploration, she was found to have bilious ascites and a sub-hepatic biloma consistent with spontaneous biliary perforation. Intraoperative cholangiogram demonstrated an intact biliary tree and normal duodenal drainage. Closed-suction drainage of the sub-hepatic collection alone led to complete resolution of symptoms.

Therapeutic experiences of 25 patients with pediatric spontaneous biliary duct perforation

Objective To summarize our therapeutic experiences on patients with pediatric spontaneous biliary duct perforation. Methods We retrospectively analyzed the clinical data of patients diagnosed as spontaneous biliary duct perforation who were admitted into the Department of Pediatric General Surgery, the Beijing Children Hospital from January 2008 to December 2014, and summarized the therapeutic experiences. Results There were 7 boys and 18 girls, with a average age of 2.4 years (range 11 months to 10 years). Twenty-one patients (84.0%) were diagnosed by ultrasonography. Two patients were treated with conservative therapy and were discharged home. The remaining 23 patients were treated with emergent surgery. Of these patients, 9 were treated with cholecystostomy and abdominal drainage (the cholecystostomy group), and the remaining 14 were treated with choledochal drainage and abdominal drainage (the choledochal drainage group). The mean hospitalization stay for the cholecystostomy group was 25.2 days, and 3 patients developed complications (33.3%). The mean hospitalization stay for thecholedochal drainage group was 16.1 day, and 2 patients developed complications (14.2%). Twenty-four patients were diagnosed to suffer from congenital choledochal cysts or pancreaticobiliary maljunction by imaging studies during or after surgery. Elective choledochal cystectomy with hepaticojejunostomy were performed on 23 stable patients who developed no severe complications. Conclusions Pediatric spontaneous bile duct perforation is closely related with congenital choledochal cysts, and the pathological basis in diagnosis is pancreaticobiliary maljunction. Bile duct elastic fiber hypogenesis and specific blood supply are important to the onset of perforation. Abdominal ultrasonography plays an important role in the diagnosis. Patients with peritoneal irritation and non-localized perforation should be operated in time, and choledochal drainage with abdominal drainage is a good treatment choice. All patients diagnosed as congenital choledochal cysts or pancreaticobiliary maljunction should undergo elective choledochal cystectomy with hepaticojejunostomy. Key words: Spontaneous bile duct perforation; Congenital choledochal cysts; Pancreaticobiliary maljunction; Choledochal drainage; Drainage tube; Cholecystostomy

Neonatal spontaneous biliary perforation: Case report

Abstract Objective Spontaneous biliary perforation in neonates is rare. The etiology of this pathology is idiopathic and various management strategies ranging from non-operative treatment to complex operations, such as biliary-enteric reconstruction, are performed, with few reported outcomes. Case report A 3-week-old female, born at term, presented fever, abdominal distension, and acholic stool. An ultrasound was performed, which revealed generalized ascites and a poorly-defined collection. An emergency laparotomy confirmed perforation in the distal common bile duct and a biliary-enteric-anastomosis was performed. Discussion Wide drainage has been reported as the best initial management strategy for spontaneous biliary perforation, although it depends on the patient's clinical status and intraoperative findings. Conclusions Spontaneous infantile biliary perforation is rare. Main management is wide drainage with, most perforations being resolved in 2 weeks.

99mTc-BrIDA cholescintigraphy in a spontaneous biliary perforation of an infant

Acute cholecystitis is a common condition which may be difficult to diagnose with confidence on clinical grounds alone. A large number of techniques are now available for imaging the gall bladder but, in practice, ultrasonography and cholescintigraphy are of greatest value. The former is cheap, readily available and features such as the presence of gall stones, gall bladder wall inflammation and a positive sonographic Murphy sign strongly suggest the diagnosis of acute cholecystitis. In addition to its diagnostic uses, ultrasonographically guided percutaneous cholecystostomy provides an alternative and sometimes life-saving form of treatment in those patients who are unfit for surgery. Cholescintigraphy is a highly accurate, non-invasive method for assessing patency of the cystic duct but is not always available in the emergency situation and takes longer to perform than an ultrasound examination. Acute cholecystitis, however, has many manifestations and may be calculous or acalculous, be associated with a patent or obstructed cystic duct, and may be complicated or uncomplicated. Imagining modalities other than those mentioned above may be useful in certain circumstances and this chapter aims to present the advantages and disadvantages of each technique in order to provide guidance for the clinician caring for a patient with suspected acute cholecystitis.

Spontaneous biliary perforation in a 7-year-old child

Spontaneous biliary perforation is a rare cause of surgical jaundice in infants and children. It typically presents in infants aged 1–12 weeks. Fewer than 200 cases have been reported in the medical literature. The lack of knowledge regarding the pathogenesis of spontaneous biliary perforation and its extreme rarity makes preoperative diagnosis and its management difficult. We report a case of a 7-year-old boy with spontaneous biliary perforation, who presented with clinical features of acute peritonitis. Cholecystectomy with simple drainage by using a T-tube resulted in satisfactory recovery. We suggest that in a jaundiced child with symptoms of abdominal pain, distension, vomiting, acholic stools, and a previous anicteric period of good health, the diagnosis of spontaneous biliary perforation should be considered if there is a triad of: (1) signs of peritonitis; (2) absence of pneumoperitoneum on erect abdominal radiography; and (3) bilious abdominal paracentesis under ultrasonographic guidance. Routine abdominal paracentesis is not recommended for infants and children. Although there are several surgical options for the disease, cholecystectomy, flushing of the bile duct and external biliary drainage, constitute the most favorable treatment. Pediatricians and surgeons should consider this disease because early surgical intervention is the only option for ensuring a favorable prognosis.

Spontaneous bile duct perforation in an infant, managed with simple drainage

Spontaneous bile duct perforation is a very rare but important cause of surgical jaundice in pediatric patients and one of the most common causes of surgical jaundice during infancy after biliary atresia. Preoperative diagnosis may not be possible in most of the cases. The exact cause of the perforation remains unclear. The diagnosis is usually made at the time of laparotomy. We report a case of spontaneous bile duct perforation in an infant and showed the successful minimal surgical intervention with T-tube insertion as the sole management.Keywords: biliary ascites, biliary peritonitis, spontaneous bile duct perforation, spontaneous biliary perforation

Intact Choledochal Cyst With Spontaneous Common Hepatic Duct Perforation

A 3-month-old girl admitted for lower respiratory infection developed constipation and abdominal distension 3 days later. On examination, she had mild abdominal distension with absent bowel sounds. Abdominal sonography showed a normal biliary tract and pancreas. Computed tomography of abdomen revealed minimal localized fluid collection in the right upper quadrant. Abdominal paracentesis done 24 hours later revealed bile-stained ascitic fluid. Exploratory laparotomy on the same day revealed intact cystic dilation of common bile duct (type 1). Operative cholangiography revealed leakage of contrast from the distal common hepatic duct with a 4-mm perforation that was sutured securely (Fig. 1). Complete excision of the cyst, cholecystectomy, Roux-en-Y hepatojejunostomy, and jejunojejunostomy were performed (Fig. 2).FIGURE 1: Sutured perforation site at the distal common hepatic duct.FIGURE 2: Excised intact choledochal cyst with gallbladder.Both spontaneous bile duct perforation and common hepatic duct perforation are rare in children (1). The unusual combination of common hepatic duct perforation coexisting with an intact choledochal cyst has not been reported previously. Clinical presentations of spontaneous perforation of bile duct and choledochal cyst are similar. Our case suggests a common underlying pathogenesis, and supports the theory that these 2 separate entities are related to weakness of the biliary canal wall during embryogenesis with pancreaticobiliary malunion (2,3). Pathobiology of spontaneous biliary perforation could be similar to that of choledochal cyst as is evident in the present case.

Spontaneous biliary perforation in infancy: Management strategies and outcomes

PurposeInfantile spontaneous biliary perforation is rare with variable management strategies ranging from nonoperative treatment to complex operations such as biliary-enteric reconstruction. Biliary fistula and portal vein thrombosis are known complications, though outcomes are poorly defined. MethodsWe assessed the incidence of spontaneous biliary perforation in infants <1year old using a population database. Next, we describe 4 patients treated at our institution and review all reported cases within the past 25years. ResultsThe incidence of spontaneous biliary perforation is 1.5 in 1,000,000 live births. Over the past 25years, 90 cases were reported, over half of which were initially managed with a surgical drainage procedure. The most common reason for failure of this strategy was CBD obstruction. Our 4 patients were successfully managed without biliary reconstruction despite 2 presenting with CBD obstruction. Reported complications occurred in 22% of patients, most frequently biliary fistula requiring delayed biliary reconstruction. ConclusionsSurgical drainage is an effective method for treatment of infantile spontaneous biliary perforation; however a persistent biliary fistula should prompt evaluation for distal CBD obstruction. Though biliary-enteric anastomosis is the historic procedure of choice for persistent fistula, with improvements in endoscopic and percutaneous treatment, extensive biliary reconstruction may be avoided in the future.

Paediatric infant presenting with an atypical spontaneous biliary perforation

Spontaneous biliary perforation (SBP) is a life-threatening condition. Although rare, it is the second most common surgical cause of jaundice in infancy after biliary atresia. SBP is theorized to occur due to a localized injury to the embryological developing biliary tree, predominantly at the junction of the cystic and the common ducts. The weakness usually develops on the anterior wall of the junction of the common and the cystic ducts. Insults to the wall, such as from infection, trauma or increased biliary pressure, can subsequently lead to perforation. We report a case of an atypical SBP in a 3-week-old girl presenting with a biloma. Keywords : biloma, paediatric, spontaneous biliary perforation, surgery

Complex spontaneous bile duct perforation: An alternative approach to standard porta hepatis drainage therapy

IntroductionSpontaneous perforation of the bile duct (SPBD) is a rare abnormality of the extrahepatic biliary tree in infants. Limited porta hepatis exploration and drainage of the bile-soiled peritoneum are often sufficient treatment. Here, we describe three cases of SPBD, one of which required complex multi-disciplinary interventions for restoration of biliary continuity. MethodsThree infants with bilious ascites from spontaneous biliary perforation were reviewed. Metrics included age, presenting symptoms, diagnostic tests, interventions performed, and outcomes. ResultsThe presenting symptoms of all three infants were bilious ascites, sepsis, lethargy, anorexia, fever and persistent emesis. SPBD was confirmed pre-operatively by HIDA scan (hepatobiliary scintigraphy) in each case. Intra-operative, trans-cholecystic cholangiogram confirmed SBDP in two cases. Two of the infants were successfully treated with placement of a cholecystostomy tube and porta hepatis drains. The third infant, having failed multiple similar drainage procedures, required percutaneous transhepatic drainage of a persistent porta hepatis biloma. Ultimately percutaneous, transhepatic cannulation of the extra-hepatic biliary tree for prolonged stenting was required to successfully treat this biliary perforation. ConclusionComplex spontaneous biliary perforation may require extensive interventions if the perforation fails to resolve with standard porta hepatis drainage. Access of the biliary tree via Interventional Radiology procedures for complex biliary disease of this type is novel and presents an alternative to traditional open surgical treatment and control of spontaneous biliary perforations.

Spontaneous Perforation of Common Bile Duct in a Pediatric Patient

We report a case of spontaneous biliary perforation in a 21-month old female pediatric patient with the presenting symptoms of abdominal distension, jaundice, and umbilical hernia. Hepatobiliary scintigraphy showed tracer accumulation in the peritoneal cavity. Preliminary diagnosis of spontaneous biliary perforation was confirmed during surgery. After surgical repair of the biliary leakage, the patient recovered fully. This case shows the importance of hepatobiliary scintigraphy in patients suspicious for this condition.

Conservative treatment of spontaneous biliary perforation

Conservative treatment of spontaneous biliary perforation

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.

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.

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.

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.

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.