A 65-year-old male was referred to the gastroenterology department with obstructive icterus. His medical history was remarkable for arterial hypertension, gastric ulcer, and chronic gastritis, diverticulosis of the colon and sideropenic anemia. He presented with epigastric abdominal pain, nausea, and heartburn. His physical examination revealed icterus of the skin and conjunctiva. His bilirubin was found to be elevated (107 mumol/l). AST and ALT were 114 IU/l and 217 IU/l, respectively. The WBC count was 10.42 x 103/mm, and segments were 24.7%.
Ultrasound revealed an elongated gallbladder (10.5 cm) filled with sludge and tiny concrements, and the common bile duct was normal in diameter, without visible intraluminal substrate. The liver was slightly enlarged with hyperechogenic parenchyma diffusely. Computed tomography (CT) of the abdomen showed normal liver structure and an enlarged gallbladder without signs of pathological changes in the wall or lumen. MRCP showed choledocholithiasis, no signs of common bile duct dilation, and normal intrahepatic bile ducts (Figure 1).
He underwent ERCP for choledocholithiasis. Access to the major papilla next to a periampullar diverticulum was obtained, and a widened common bile duct was shown with small concrements prepapillary. A sphincterotomy and concrement extraction with a balloon was performed. The procedure passed without complications.
While waking up from the sedation, the patient immediately complained about abdominal pain. The gastroenterologist found the abdomen to be distended and referred the patient to an urgent CT of the abdomen. The WBC was 10.42 x 103/mm. On CT, free air was found around the duodenum in level of the papilla in the retroperitoneum and around the liver equaling pneumoperitoneum and pneumoretroperitoneum (Figure 2). Postprocedural pneumobilia in the gallbladder, cystic duct, common bile duct, and intrahepatic bile ducts was found. Free contrast was found around the gastric fundus (Figure 3), paracolical, and pelvis, and the radiologist suspected duodenal perforation.
The patient was referred urgently to the general surgery department. The patient's abdomen was found to be distended with signs of peritonitis, no audible peristalsis. The patient was rushed to an emergency laparotomy. Intraoperative biliary peritonitis was found. After thorough exploration of the upper abdomen and kocherization of the duodenum and head of the pancreas, no perforation of the duodenum or common bile duct was found. Hence, retroperitoneal perforation as the source of the intraperitoneal biliary collection could be excluded. Only when removing the liver retractor on the anterior side of the III, liver segment ruptured, but otherwise, normally appearing bile duct was found with bile secretion into the peritoneal cavity (Figure 4). The defect was closed with sutures. A choledochotomy was performed, and a T-drainage positioned to facilitate the biliary drainage. Cholecystectomy, lymphadenectomy, and omentectomy were performed too. Since the site of the intrahepatic bile duct rupture was clearly seen, no indication for an intraoperative cholangiography was found; hence, the rupture of the intrahepatic bile duct was not confirmed radiologically during surgery. The procedure ran without complications.
The postoperative recovery was uneventful. A cholangiography was performed which excluded the presence of any aberrant intrahepatic bile ducts (Figure 5). The patient did not develop jaundice postoperatively. The patient was discharged on POD 15.