Spontaneous common bile duct perforation in an adult female patient presenting with severe epigastric pain mimicking acute pancreatitis

Spontaneous non-traumatic common bile duct perforation presented as an acute abdomen: a rare case report

“…In diagnosis-delayed cases or large perforations with gross ascites in sepsis laparotomy with cholecystectomy and CBD closure over T-tube is treatment of choice. 4 In most cases, the encapsulation of the bile within the omentum and mesentery prevents generalized peritonitis, forming biomass; which are generally localized in the right upper quadrant of the abdomen. As the bile is sterile and is absorbed by the peritoneum, the patients may not present symptoms for weeks, until the bile becomes superinfected, thus the diagnosis is delayed by weeks.…”

“…Few cases have been reported and published since 1882, first case was clinically described by Freeland in1882. [1][2][3][4]7 , as of 2004 to date only around 70 cases have been reported in English literature with few more additions, a total of 97 cases in past 135 years have been reported. 1 Perforation of the biliary tract is a disease in which wall of the intrahepatic or extrahepatic duct is perforated non-traumatically or due to iatrogenic injury.…”

Spontaneous extrahepatic biliary tree perforation

“…Since the first documentation of this entity in 1882 by Freeland, 1 a further 90 adult cases have been reported. 1,2 Perforation of the bile duct is far more common in the paediatric population due to congenital anomalies. 3 Pathogenesis of the extrahepatic biliary tree perforation is not completely understood, although distal obstruction as well as wall weakness or a combination of these factors in conjunction with biliary calculous disease has been strongly implicated.…”

“…Other conditions implicated in spontaneous perforation include connective tissue disorders, rupture of a diverticulum, choledochal cysts, birth trauma, choledochal tuberculosis, HIV, parasites, pancreatic reflux, elevated intraductal pressure following sphincter of Oddi dysfunction, tumours, and biliopancreatic junctional pathology. 1,[3][4][5][6][7] Idiopathic perforations may be due to arterial thrombosis and poor ductal perfusion resulting in ischaemia, necrosis and subsequent perforation. 8 We postulate that the aetiology in our patient was multifactorial as she had underlying connective tissue disease, was on chronic steroid therapy, likely had pancreatic reflux, intra-ductal infection and increased intra-ductal pressure due to a temporary gallstone impaction or oedema at the ampulla of Vater.…”

“…Any attempt at more extensive surgery may significantly contribute to morbidity without benefit. 1,[4][5][6]11 In all cases wide drainage of the sub-hepatic space is mandatory. Biopsy of the perforation site is important to exclude a systemic cause for the perforation.…”