Retroperitoneal Biloma due to Spontaneous Perforation of the Left Hepatic Duct

Abstract

Patient: Male, 82Final Diagnosis: Retroperitoneal biloma due to spontaneous perforation of the left hepatic ductSymptoms: Abdominal pain • high feverMedication: —Clinical Procedure: Emergent operationSpecialty: Gastroenterology and HepatologyObjective:Rare diseaseBackground:Spontaneous perforation of the bile duct in adults is very rare, particularly in cases accompanied by retroperitoneal biloma. We report a patient with retroperitoneal biloma due to a spontaneous perforation of the left hepatic duct.Case Report:An 82-year-old man was admitted to our institution with abdominal pain and a high fever. He had tenderness at the epi-mesogastrium. Computed tomography showed several stones in the gall bladder and common bile duct (CBD) and a few ascites. A substantial amount of fluid had collected from the dorsal stratum of the duodenum and pancreas head to the right paracolic gutter and anterior side of the right iliopsoas. Laboratory examination revealed a high inflammation score. He underwent emergent laparotomy. Biliary fluid was revealed after the mobilization of the pancreas head, duodenum, and right side of the colon. Bile duct perforation was suspected. Therefore, we exfoliated the dorsal side of the CBD to the cranial side, and intraoperative cholangiography was performed. However, the perforation site could not be detected. Cholecystectomy and choledocholithotomy were performed. A retrograde transhepatic biliary drainage tube was inserted, and primary closure of the CBD incision site was achieved. Postoperative cholangiography revealed leakage from the left hepatic duct near the caudate branch.Conclusions:There are a few reports of spontaneous bile duct perforation cases in the literature, particularly on infants or children with congenital anomalies, but it is rare in adults. It usually causes bile peritonitis, although bile duct perforation should be considered in the differential diagnosis of spontaneous retroperitoneal fluid collection in adults.

Spontaneous biliary peritonitis and retroperitoneal biloma: an unusual presentation of a common disease

“…The proposed pathophysiological mechanisms for spontaneous biliary perforation include increased intraductal pressure secondary to biliary obstruction, 2,5 thrombosis of intramural vessels leading to necrosis, 2,5 erosion by ductal stones, 2,5 intramural infection and pancreatitis. 5 In this case, the intraoperative cholangiogram demonstrated complete obstruction of the common channel and a patent pancreatic duct. It is postulated that increased ductal pressure from obstruction, combined with acute pancreatitis, has led to disruption of the pancreatic duct and retrograde flow of bile into the retroperitoneum.…”

“…The proposed pathophysiological mechanisms for spontaneous biliary perforation include increased intraductal pressure secondary to biliary obstruction, thrombosis of intramural vessels leading to necrosis, erosion by ductal stones, intramural infection and pancreatitis . In this case, the intraoperative cholangiogram demonstrated complete obstruction of the common channel and a patent pancreatic duct.…”

“…Rare cases have been reported of spontaneous bile duct rupture leading to either biliary peritonitis or retroperitoneal biloma. [1][2][3][4][5] In this case, we describe both biliary peritonitis and retroperitoneal biloma secondary to disruption of the pancreatic duct in the setting of acute pancreatitis. To our knowledge, this has not been described previously.…”

Refractory peritonitis by spontaneous perforation of the common bile duct in a patient receiving peritoneal dialysis

“…To our knowledge, the present case is the first report of perforation of the bile duct in a patient receiving PD, independent of catheterrelated mechanisms. Spontaneous perforation of the bile duct in adults may occur in the following situations: erosion by gallstones, increased intraductal pressure due to obstruction of the distal bile duct, thrombosis or ischemia of the bile duct wall, intramural infection of the duct as a result of cholangitis, regurgitation of pancreatic secretions into the bile duct, bile duct diverticulitis, and acute pancreatitis [15]. One of the most frequent causes of spontaneous perforation of the bile duct is biliary stones, especially after choledocholithiasis.…”

A giant and insidious subphrenic biloma formation due to gallbladder perforation mimicking biliary cystic tumor: A case report

“…CT cholangiography and cholescintigraphy are non-invasive and effective means of demonstrating the presence and site of biliary excretion, complementing the MRCP in selected cases and avoiding the requirement for endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography (18,19). In exceedingly rare cases, however, a pinhole-sized perforation may escape detection on medical imaging, even when intraoperative cholangiography is performed (20).…”