MASSIVE COMMON BILE DUCT GANGRENE OF OBSCURE ETIOLOGY ENCOMPASSING THE ENTIRE HEPATO-DUODENAL LIGAMENT IN A CLINICALLY SILENT ADULT: WORLD’S FIRST CASE Translated title: GANGRENA MACIÇA DO DUCTO BILIAR PRINCIPAL DE CAUSA OBSCURA, COMPROMETENDO O LIGAMENTO HEPATODUODENAL INTEIRO EM UM ADULTO CLINICAMENTE ASSINTOMÁTICO: PRIMEIRO CASO DO MUNDO

Background. Spontaneous perforation of the extrahepatic biliary system is a rare presentation of gall stones. Very few cases of bile duct perforation have been reported in adults. It is rarely suspected or correctly diagnosed preoperatively. Case Presentation. A 66-year-old female presented at the surgical emergency with 3 days' history of severe upper abdominal pain with distension and repeated episodes of vomiting, as she had evidence of generalized peritonitis and underwent an exploratory laparotomy. A single 0.5 cm × 0.5 cm free perforation was present on the anterolateral surface of the common bile duct at the junction of cystic duct. A cholecystectomy and the CBD exploration were performed. Conclusion. Spontaneous perforation of the extrahepatic bile duct is a rare but important presentation of gall stones in adults. Therefore, awareness of the clinical presentation, expert ultrasound examination, and surgery are important aspects in the management.

Spontaneous biliary peritonitis is rare in adults. We herein report a case of spontaneous biliary peritonitis. An 84-year-old man was admitted to our hospital for abdominal pain for 5 days. He developed fever, jaundice, and abdominal rigidity. Computed tomography (CT) revealed massive ascites in the omental bursa and around the liver. The ascites obtained by diagnostic paracentesis was dark yellow-green in color, which implied bile leakage. With a diagnosis of bile peritonitis, the patient underwent emergency exploratory laparotomy. There was massive biliary ascites in the abdominal cavity, especially in the omental bursa. Because exploration failed to demonstrate the perforation site in the gallbladder and biliary duct, we performed abdominal lavage alone. Postoperative endoscopic retrograde cholangiopancreatography showed stones in the common bile duct, and there was no evidence of biliary leakage. Endoscopic retrograde biliary drainage was performed using a plastic stent to reduce the pressure of the common bile duct. After the operation, the patient showed satisfactory recovery and started oral intake on postoperative day 8. However, the patient developed heart failure due to renal dysfunction with nephrotic syndrome at 1 month after the operation. With a diagnosis of rapidly progressive glomerulonephritis due to immune complex, the patient received steroid treatment for nephritis, diuretics, and carperitide for heart failure. Although heart failure and renal dysfunction improved by these treatment, the patients developed toxic epidermal necrolysis which was refractory to intensive treatments including steroid pulse and immunoglobulin, and the patient died 76 days after the operation.

Spontaneous perforation of the bile duct is a rare disease in children and even rarer in adults. Although diagnostic techniques have advanced over the past years, yet most cases are diagnosed at operation. A 44-year-old woman presented with epigastric pain and vomiting of one-day duration. Abdominal distension with tenderness and guarding was present all over the abdomen. Abdominal ultrasonography showed free fluid in the peritoneal cavity with sluggish peristalsis. Abdominal and chest radiographs were normal. At laparotomy, common bile duct CBD was perforated at the junction of CBD and cystic duct. Cholecystectomy with CBD exploration was done and CBD was closed over a T-tube, and external drainage was carried out. The patient recovered well, and on the 12th postoperative day, a T-tube cholangiogram was performed which was normal. The T-tube was removed on the 14th postoperative day. One month after operation, the patient was well. Examining the patient with a suspicious thinking helps in early diagnosis and management of the patient.