Perforación espontánea de la vía biliar en un neonato: un hallazgo inesperado: caso clínico / Spontaneous perforation of the bile duct in a neonate: an unexpected finding: case report

La perforación espontánea de la vía biliar extrahepática es rara en recién nacidos. Es una causa quirúrgica de ictericia en este período y la presentación aguda es inusual. OBJETIVO: presentar un caso de perforación espontanea de la vía biliar en un recién nacido por sus graves complicaciones si no se realiza un diagnóstico temprano y oportuno. CASO CLÍNICO: Recién nacido de término de 10 días de vida que consultó por cuadro de rechazo alimentario, fiebre y distensión abdominal de 2 días de evolución, sin ictericia, acolia, ni coluria. En los exámenes de laboratorio se encontró leucopenia, trombocitosis y elevación de la proteína C reactiva, con función hepática normal. La radiografía de abdomen demostró neumoperitoneo, sospechándose enterocolitis necrosante, se realizó laparotomía, encontrándose perforación espontánea de la vía biliar extrahepática y peritonitis biliar. La colangiografía intraoperatoria demostró la vía biliar proximal rescatable y conducto cístico dilatado. Se realizó hepático-yeyunostomía con Y de Roux transmesocolónica y colecistectomía. En el estudio postoperatorio se encontró trombosis portal, por lo que recibió tratamiento anticoagulante. En el control a los ocho meses de edad, la paciente tenía buena tolerancia oral y adecuado incremento ponderal. CONCLUSIONES: La perforación biliar es una entidad rara y más en el período neonatal, condición que la vuelve un reto diagnóstico y terapéutico. El pronóstico dependerá de la intervención temprana y los hallazgos intraoperatorios.

Spontaneous extrahepatic bile duct perforation is rare in newborns. It is a surgical cause of jaundice in this period and the acute presentation is unusual. OBJECTIVE: To report a case of spontaneous bile duct perforation in a newborn due to its serious complications if an early and timely diagnosis is not performed. CLINICAL CASE: A 10-day-old newborn who developed food rejection, fever and abdominal distension without jaundice, acolia, or coluria two days prior of admission. The laboratory tests showed leukopenia, thrombocytosis, increased C-reactive protein, and normal hepatic function. The abdominal x-ray showed pneumoperitoneum, and the diagnosis of necrotizing enterocolitis was made. Laparotomy was performed; extrahepatic bile duct perforation and biliary peritonitis were noted. Intraoperative cholangiography demonstrated rescatable proximal bile duct and dilated cystic duct. Hepatic-jejunostomy was performed with Roux-en-Y and cholecystectomy. In the postoperative study portal thrombosis was found, so he received anticoagulant treatment. At 8 months of age, the patient had enteral feeding tolerance and adequate weight gain. CONCLUSIONS: Biliary perforation is a rare entity and more in the neonatal period, a condition that makes it a diagnostic and therapeutic challenge. The prognosis will depend on early intervention and intraoperative findings.

Gallbladder Perforation without Gallstones or Cholecystitis

A case of gallbladder perforation without cholecystitis or trauma is described herein. The patient was a 74-year-old woman who initially presented with right lower quadrant pain of the abdomen. A laparotomy was performed with the impression of an acute appendicitis at a local clinic. However, the appendix was normal and a large amount of bile was noted in the peritoneal cavity. The patient was referred to our hospital. An exploratory laparotomy was performed with the suspicion of a hollow viscous perforation. A pin point perforation of the gallbladder fundus was identified. There were no gallstones or definite inflammation of the gallbladder wall. Although gallbladder perforation without cholecystitis or trauma is rare, gallbladder perforation without cholecystitis should be considered in elderly patients with bile peritonitis of unknown etiology.

Bile Peritonitis Due to Spontaneous Rupture of Choledochal Cyst iagnosed by Hepatobiliary Scintigraphy in an Infant / 대한소아소화기영양학회지

Choledochal cyst is a congenital anomaly with classic triad of abdominal pain, jaundice and right upper abdominal mass. Bile peritonitis caused by cyst rupture is relatively not rare in infancy. The mechanism of rupture must be epithelial irritation of the biliary tract by refluxed pancreatic juice caused by pancreatico-biliary malunion associated with mural immaturity in infancy, rather than an abnormal rise in ductal pressure or congenital mural weakness at a certain point. We experienced a case of bile peritonitis caused by spontanenous rupture of choledochal cyst in a 10-month-old girl presented with abdominal distension, persistent fever, diarrhea, irritability and intractable ascites. She was presumed as having bile peritonitis by bile colored ascitic fluid with elevated bilirubin level and diagnosis was made by 99mTc DISIDA hepatobiliary scan showing extrahepatic biliary leak. The perforated cyst was surgically removed and the biliary tree was reconstructed with a Roux-en-Y hepaticojejunostomy.

Bile Duct Injury during Laparoscopic Cholecystectomy

PURPOSE: Laparoscopic cholecystectomy has replaced open surgery as the standard treatment for symptomatic cholelithiais. The combined use of ERCP and endoscopic sphincterotomy makes it possible for the diagnosis and management of common bile duct stones also. The authors reviewed cases for complications and clinical results in order to elucidate the efficacy of laparoscopic cholecystectomy in our hospital. METHODS: Of the 996 subjects who underwent laparoscopic cholecystectomy in our hospital between 1994 to 2000, only subjects of bile duct injury during or after the surgery were chosen for study. The clinical signs, symptoms, laboratory data, treatment method and complications were reviewed retrospectively. RESULTS: 8 patients developed bile peritonitis (0.81%), and 2 of these died of complications. Abdominal pain was noted in all patients. Intraabdominal bile collection was detected with ultrasonography (6 cases), endoscopic retrograde cholangiopancreatography (6 cases), percutaneous transhepatic cholangiography (3 cases) and computerized tomography (1 case). Management of bile peritonitis was done with Roux-en-Y hepaticojejunostomy (3 cases), naso-biliary tube drainage (2 case), sono-guided bile drainage (1 case) and primary closure of the common bile duct (2 case). CONCLUSION: This study demonstrated that laparoscopic cholecystectomy is a relatively safe and effective approach for the management of gallstones. And though vague and nonspecific, there were clinical signs and symptoms revealing bile leakage such as abdominal pain, tenderness, fever, jaundice and so on. Therefore, prompt and proper management for bile leakage should be accomplished to prevent lethal outcome.

Bile Peritonitis Due To Choledochal Cyst Perforation In Infants

Choledochal cyst is rare in the Western countries, but common in the Oriental countries. The reported complicatioins of choledochal cyst are ascending cholangitis, recurrent pancreatities, progressive biliary cirrhosis, portal hypertension, stone in the cyst, and malignant in the biliary tract. Bile peritonitis secondary to rupture is one of the rarest complications of choledochal cyst, and its reported incidence was 1.8% (Yamaguci, 1980) to 18% (Karnak et al, 1997). The exact cause of perforation of choledochal cyst is unknown, but an anomalous arrangement of the pancreatobiliary ductal system with a long common channel may contribute to the formation of choledochal cyst and even perforation of cyst.Authors reviewed 4 cases (14.2%) of bile peritonitis among 28 cases of choledochal cyst in infants from Jan. 1983 to Jan. 1998. Their ages ranged from 6 months to 3 years and three of them were female. Abdominal distension, pain, and vomiting were common symptoms, and clinical jandice and palpable mass were present in one case. Pre-operative laboratory investigations showed elevated serum bilirubin, serum AST and serum ALT in 3 cases, and elevated serum amylase in one case. The perforation sites were located on the common bile duct at its junction with the cystic duct in 2 cases, distal cyst wall in 1 case and left hepatic duct at its junction with cyst in 1 case. The types of choledochal cysts according to Todani's classification (1977) were as follows;Type IVa was in 3 cases, type I was in 1 case. The results of operative cholangiogram according to new Komi's classification (1992) were as follows;Type Ia was 2 cases, type IIb 1 case, and type III 1 case. One stage primary cyst excision and hepaticojejunostomy(Roux-en Y type) was done in 3 cases, and two staged operation in 1 case. All patients have recovered unevenfully after surgery and discharged at post -operative 9.8th day averagely. Authors concluded that the primary choledochal cyst excision with biliary recontinuity was a safe surgical procedure in ruptured choledochal cyst in infants.

Childhood appendicitis in Korea

Bile peritonitis due to spontaneous perforation of choledochal cyst is a rare disease and the etiology of spontaneous perforation is unknown in most of infant cases. Recently, we experienced a case of bile peritonitis caused by spontaneous perforation of choledochal cyst in a 6 month-old female infant. She had progressive abdominal distention with ascites, mild jaundice and intermittent passage of acholic stool. Presence of bile in ascitic fluid was revealed by peritoneal tapping. Bile peritonitis from the perforation of choledochal cyst was confirmed by explorative laparotomy and operative cholangiogram. She had discharged with good condition after choledochal cystectomy and Roux-en-Y choledochojejunostomy. A brief review related literatures is also presented.