Spontaneous perforation of common bile duct: a rare complication of choledocholithiasis.

A 35-year-old female presented with 48 hrs history of severe upper abdominal pain and abdominal distension. The patient was suffering from intermittent episodes of colicky upper abdominal pain and spiky fever with chill and rigor in association with yellowish discoloration of eyes and urine for last 3 months. On examination the lady was dehydrated, icteric, febrile and was having tachycardia and hypotension. Abdominal examination indicated features of generalized peritonitis. Hematological profile suggested neutrophilic leukocytosis, blood biochemistry suggested conjugated hyperbilirubinemia, raised alkaline phosphatase and transaminases. Skiagram of the abdomen showed ground glass opacity without any free gas under the diaphragm. Ultrasonography and contrast enhanced CT scan of the abdomen revealed multiple calculi within a distended, thick walled gall bladder, dilated common bile duct (CBD) with a 12.8 mm stone impacted at its lower end and free fluid in the lesser sac and rest of the peritoneal cavity. Diagnostic abdominal paracentasis showed heavily bile stained fluid. Exploration done for generalized biliary peritonitis with sepsis, revealed erosion at the posterior aspect of the retro-duodenal CBD over the site of the impacted stone. She underwent cholecystectomy, choledocholithotomy through a supra-duodenal choledochotomy, and T-tube drainage of the CBD. She made a slow but steady post operative recovery and was discharged from the hospital after 22 days in favorable conditions.

Mesenteric cyst: an unusual presentation.

A 5-year-old boy presented with the history of a small lower abdominal swelling since childhood which increased in size and became painful following a fall. Examination revealed a mobile, globular, cystic intraabdominal mass in the lower abdomen. Ultrasonography of the abdomen suggested a 7.5 × 5.5 cm cystic lesion, separate from the bladder, containing an echogenic mobile mass. Intra venous urography excluded any abnormality of the kidneys, ureters and bladder. Exploratory laparotomy revealed a sigmoid mesenteric cyst protruding out of one of the mesenteric leaves and attached to it by a narrow stalk. The excised cyst was found to be thin walled and unilocular. It was internally lined with fibrinous exhudate and contained serous fluid and a solid spherical blood clot. The child had an uneventful postoperative recovery. Histopathology of the cyst wall showed maturing granulation and fibrous tissue with hemosiderin laden macrophages and lymphoid aggregates consistent with the diagnosis of a lymphagioma with chronic inflammatory changes and evidence of past hemorrhage.