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Management of common bile duct obstruction associated with spontaneous perforation of the biliary tree
1Department of Surgery, University of Texas Southwestern Medical School, Dallas.
Insights
Infantile biliary tree perforation, often linked to distal obstruction, may resolve spontaneously. Expectant management of stones or sludge could be safer than immediate surgical intervention during acute inflammation.
Area of Science:
- Pediatric Surgery
- Hepatobiliary Disorders
- Medical Imaging in Pediatrics
Background:
- Spontaneous perforation of the extrahepatic biliary tree is a rare neonatal condition.
- Distal common bile duct obstruction by stones or sludge is implicated in approximately 25% of cases.
Observation:
- A 4-week-old infant presented with jaundice and biliary tree perforation confirmed by DISIDA scan (99m technetium diisopropyl iminodiacetic acid).
- Exploratory surgery revealed distal common bile duct obstruction with proximal perforation; the obstructing lesion was not removed due to inflammation.
Findings:
- The common bile duct obstruction resolved spontaneously by week 5 post-surgery, as evidenced by normal cholangiography.
- The case suggests that spontaneous passage of the obstructing stone or sludge is possible.
Implications:
- Surgical exploration to relieve distal common bile duct obstruction in the setting of acute biliary inflammation may be hazardous.
- Expectant management of distal common bile duct stones or sludge in neonates with biliary perforation warrants consideration.
- This approach may avoid complications associated with aggressive surgical intervention during acute inflammatory phases.
Abstract:
Spontaneous perforation of the extrahepatic biliary tree during infancy is an uncommon event. The cause of bile duct perforation is unclear, but one-quarter of reported cases have been associated with a stone or bile sludge obstructing the distal common bile duct. A 4-week-old girl had jaundice, and a DISIDA (99m technetium diisopropyl iminodiacetic acid) scan revealed perforation of the biliary tree. Exploratory surgery showed distal common bile duct obstruction with proximal perforation. No attempt was made to remove the obstructing lesion because of duct inflammation. Common bile duct obstruction persisted until week 5 after surgery when cholangiography revealed free flow of contrast into the duodenum through a common bile duct of normal caliber without a filling defect. In the presence of acute inflammation associated with perforation of the biliary tree, exploration of the common bile duct to relieve a distal obstruction could prove hazardous. Our case and a review of the literature suggest that the obstructing stone or sludge may pass spontaneously if managed expectantly.