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Case Report

Indian Pediatrics 1999; 36:192-194 

Idiopathic Spontaneous Rupture of Bile Duct

Shivananda
M.L. Siddaraju
Siddappa*
Gayathri P.
 

From the Departments of Pediatrics and Pediatric Surgery,* Vani Vilas Children's Hospital, Bangalore, India.

Reprint requests; Dr. Shivananda, No. 608, 7th main, III Stage, III block, Basaveswaranagar. Bangalore 560 079, India.

Manuscript Received: June 10, 1998; Initial review completed: July 16, 1998;
Revision Accepted: August 14,1998.

 

Idiopathic spontaneous perforation of the bile duct is rare, though bile ascites secondary to perforation of choledochal cyst or blunt trauma have been reported(1-3). We are reporting one such case.

Case Report

A I5-month-old female child born of a non consanguineous marriage presented with history of abdominal distension and passing clay colored stools of IS days duration. On examination the child had mild icterus, abdominal distension, and mild pedal edema. Per abdomen examination revealed the pres- ence. of free fluid, there was no organomegaly. On investigation the total bilirubin was found to be 2.1 mg/dl, direct bilirubin 0.9 mg/dl, SGOT 27 lU/L, SGPT 34 lU/L, and serum alkaline phosphatase was raised to 178 lU/L. Serum proteins, serum albumin and A:G ratio were normal. Prothrombin time was also within normal limits. Urine examinationre- vealed the presence of bile salts and pigments. Ultrasound abdomen confirmed the presence of free fluid and also revealed dilated biliary radicles. A possibility of biliary obstruction preceding the perforation was contemplated. Results of hepatobiliary scintigraph demonstrated that the intraperitoneal fluid originated from the biliary tract. Abdominal paracentesis was done and the tap confirmed the presence of bile in the peritoneal cavity.

The child was taken up for explorative laparotomy as the cause for the bile leak could not be ascertained by the investigations. At laparotomy, bile Was found in the peritoneal cavity and as the site of leak could not be clearly made out, normal saline was injected through the gall bladder which came out through an opening about I x I cm on the right hepatic duct which was sealed with an omental patch. Post operatively, bile continued to leak through the abdominal drain for about a week and subsequently subsided. Post operative isotope study revealed the entry of bile into the duodenum. Post operative ultra- sound showed resolution of the dilated biliary radicles.

Discussion

The rarity of spontaneous perforation of t>ile ducts in the absence of trauma or previous biliary surgery is apparent by the few reports in the literature. In most cases the etiology is not apparent but important factors may be weakening of the common bile duct wall due to ischemia or pancreatic juice, reflux associated with a rise in choledochal pressure, trauma, or due to gall stones. Donald et at. have reported two cases, one occurring in the distal common bile duct and one in a small superficial hepatic duct radical on the inferior surface of the liver(4). In our child, a perforation I x I cm was noted on the right hepatic duct. Spontaneous rupture of the common bile' duct may result from increased intraductal pressure with associated calculous, erosion and necrosis of the bile duct wall secondary to thrombosis(S). Spontaneous perforation of the common bile duct is seldom listed as a cause of obstructive jaundice(6). Two cases were reported by Kersteen et at. one related to calculous erosion and the other un~ explained(5). In the present case, no cause for the perforation could be found. In older children, the onset of biliary ascites may be preceded by acute gastrointestinal illness which may be a predisposing factor(5,7). Free bile or bile stained fluid in the peritoneal cavity with an intact gall bladder should alert the surgeon to the possibility of bile duct perforation(6,8). Awareness of this diagnosis may help in avoiding time consuming and un- necessary investigations and initiate surgical exploration as early as possible(8). In conclusion, one can entertain the possibility of spontaneous rupture of bile duct as a cause of acute biliary ascites.

 

References


1. Chaturvedi A, Lodha A, Gupta S, Sharma V, Sahni N, Bothra Gc. Bile ascites. Indian Pediatr 1995; 32: 251-255.

2. Sarin YK, Singh VP. Biliary ascites caused by perforation of choledochal cyst. Indian Pediatr 1995; 32: 815-817.

3. Bayer KT, Charmoff C. Spontaneous rupture of the common bile duct. Can J Surg 1986; 29: 68-69.

4. Donald JW, Ozment ED. Spontaneous perforation of bile ducts. Am Surg, 1977; 43: 524-527.

5. Kersteen, McSwain NE. Spontaneous rupture of common bile duct. Am J Gastroenterol 1985; 80: 469-471.

6. Enell H, Cavell B, Malmfors G. Spontaneous perforation of common bile duct. Acta Paediatrican Scand 1979; 68: 625-626.

7. Lloyd DA, Mickel RE. Spontaneous perforation of the extra hepatic bile ducts in neonates and infants. Brit J Surg 1980; 67: 621-623.

8. Haller JO, Condon YR, Berdon WE, Oh KS, Price AP. Spontaneous perforation of common bile duct in children. Radiology 1989; 172; 621-624.

 

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