Spontaneous perforation of the extrahepatic biliary system is a rare presentation of ductal stones. We report the case of a twenty-year-old woman presenting at term with biliary peritonitis caused by common bile duct (CBD) perforation due to an impacted stone in the distal common bile duct. The patient had suffered a single herald episode of acute gallstone pancreatitis during the third trimester. The patient underwent an emergency laparotomy, bile duct exploration, and removal of the ductal stone. The postoperative course was uneventful.
Perforation of the biliary system occurs
most frequently in the gallbladder, usually associated with (and complicating
upto 10 % cases of) acute cholecystitis. Perforation of the extrahepatic biliary
tree is a rare entity, accounting for less than 10 % of intraperitoneal biliary
rupture [
Bile
duct perforation is most commonly described in infants related to congenital
biliary system anomalies. Aetiology in the adult is commonly attributable to
intramural infection, necrosis of the wall of the bile duct secondary to
thrombosis, increased intraductal pressure secondary to obstruction, cirrhosis,
and direct erosion by calculi. Overall, 70 % of cases are related to calculi
[
The
incidence of biliary tract disease during pregnancy ranges from 0.05–0.3 % [
A twenty-year-old primigravida woman was
planned for elective caesarean section due to breech presentation. The patient
had a past medical history of
At 34 weeks gestation, she presented
acutely with a two-week history of worsening abdominal pain localised to the
epigastric region, associated with vomiting. On examination, tenderness was localised to the epigastrium and right upper quadrant. Blood
results revealed raised inflammatory markers (WBC 14.4 [4.0–11.0],
neutrophils 11.9 [2.0–7.5], CRP 60
[0–7.5]) and evidence of pancreatitis (amylase 1369 IU/L [36–128]), mildly
raised bilirubin (24
Six weeks later, she was readmitted with severe abdominal pain. She was pyrexial (39.3°C), tachycardic, and hypotensive. Abdominal examination revealed severe generalised abdominal tenderness with evidence of peritonism. An emergency caesarean section was performed and a term baby delivered, but no obvious cause was found to explain her clinical condition.
The
following day her clinical condition worsened, with progressive abdominal pain
and a metabolic
acidosis. She required aggressive resuscitation, inotropic, and ventilatory support and was,
therefore, admitted to the intensive care unit. A computed tomography (CT)
revealed extensive free peritoneal fluid and gas of which the aetiology was not
apparent. The patient underwent a prompt laparotomy and was found to have
generalised biliary peritonitis. The gallbladder was intact but a 2 mm
perforation was found on the anterior surface of a dilated common
bile duct (12 mm). On table cholangiography suggested obstruction of the distal
common bile duct caused by a 5 mm gallstone impacted within the distal common
bile duct.
The calculus was removed, and the duct was repaired over a T-tube. Repeat
cholangiography showed no residual obstruction. The patient had an uneventful postoperative recovery and was
discharged on day seven. A T-tube cholangiogram was performed
after 4 weeks, and the tube was uneventfully removed (Figure
Postoperative T-tube cholangiogram illustrating normal duodenal filling with no visible bile duct filling defect.
Although
the pathogenesis of spontaneous biliary perforation is poorly understood,
recognised mechanisms include the following: calculous perforation at the site
of impaction; calculous erosion without impaction; increased canalicular
pressure due to obstruction by tumour, stone, or spasm of the sphincter of
Oddi; intramural infection; mural vessel infarction leading to mural necrosis;
or rupture of a biliary tract anomaly such as cyst or diverticulum [
As
early as 1882, Freeland [
Petrozza
et al. [
Several
reports exist of successful laparoscopic cholecystectomy during pregnancy.
Block and Kelly [
Unfortunately, in those women presenting late in pregnancy (as in the case described), the balance of risk favours watchful waiting until after delivery followed by elective cholecystectomy. Certainly, this risks early recurrence of acute pancreatitis, as well as rare but severe consequences such as biliary peritonitis. Whether an early endoscopic retrograde cholangiopancreaticography (ERCP) and sphincterotomy in those cases presenting with gallstone pancreatitis can be an acceptable temporary preventive measure is unclear, but undertaking ERCP is not without risk, and the potential risks should be considered carefully in individual cases. In this particular case, it is impossible to know whether the eroding calculus had been present during the initial episode of pancreatitis. Magnetic resonance scanning is a commonly used imaging modality in obstetrics, considered to be safe and avoiding the use of ionising radiation. Therefore, magnetic resonance cholangiopancreatography (MRCP) would have been a reasonable next investigation during this patient’s initial presentation, and if a ductal stone had been revealed, then the indication for ERCP may have been clearer.
On the other hand, neonatal and postnatal care of babies born early have progressed significantly, suggesting the possibility of induction of labour perhaps at 36–38 weeks gestation in severely symptomatic or high-risk patients. Of course, every case must be considered individually, taking into account maternal and fetal history and health.