A Rifai, SM Shabib, A Al-Rabia, Imaging Findings of Spontaneous Perforation of Common Bile Duct in an Infant. 1998; 18(4): 335-336 Biliary leak can be readily demonstrated with hepatobiliary scintigraphy. Ultrasound and CT can define biliary collections, but cannot easily determine if there is an active leak. We describe a distinctive pattern of spread of the radioactive biliary agent (Tc-disofenin) in the peritoneal cavity, and a secondary reversible parenchymal change in the liver on CT scan, in an infant with a spontaneous rupture of the bile duct. Case ReportAn eleven-month-old infant presented with fever, vomiting and diarrhea. A transient jaundice lasting for four days developed, and was followed by severe abdominal distension associated with whitish stool and drop in weight. There was no history of trauma and the infant had been in good health before this. On physical examination, the infant was mildly distressed. The abdomen was distended with shifting dullness and there was bilateral greenish hydrocele. Urine analysis was normal and the stool was free of bilirubin. Serum bilirubin was 36 mmol/L, alkaline phosphatase 139 units/L, ALT 49 units, total protein 44 g/L, albumin 21 g/L, and PT was 18.4 sec. Diagnostic peritoneal tap revealed 60 WBCs (polymorph. 82%, lymphocytes 16%) and cholesterol 6.8 units. The ascitic fluid bilirubin was 365 mmol/L and the PTT was 58.9 sec. The gram stain and culture of the ascitic fluid were negative and blood culture showed no bacterial growth. Diagnostic Imaging EvaluationUltrasound showed a large amount of free ascites in the abdomen and pelvis, the gallbladder could not be seen, and the liver appeared diffusely echogenic. The CT scan (Figure 1) showed a low-density liver (2 to 12 Hounsfield units), consistent with fatty infiltration. The gallbladder was contracted. The ascitic fluid appeared slightly dense, measuring 15-20 Hounsfield units. Technetium 99m DNA scan using disofenin showed good uptake in the liver, with focal accumulation of radioactivity in the hilum of the liver appearing in a peanut shell-like collection ( Figure 2A). This collection appeared to leak in a branching linear pattern downwards caudally to the right of the midline, and transversely to the left along the mesenteric root and mesocolon boundaries ( Figure 2B). The radioactivity subsequently extended down to the pelvis and ascended to the left side of the abdomen, filling the peritoneal cavity ( Figure 2C).