Spontaneous common bile duct perforation due to chronic pancreatitis, presenting as a huge cystic retroperitoneal mass: a case report
© licensee BioMed Central Ltd. 2009
Received: 1 March 2009
Accepted: 28 July 2009
Published: 8 September 2009
Spontaneous perforation of the bile duct, is a disease in which spontaneous perforation occurs in the wall of the extrahepatic or intrahepatic duct without any traumatic or iatrogenic injury and more often described in neonates. In this report, we present a 38-year-old female patient who underwent surgery due to an intraabdominal cystic mass. The diagnosis of spontaneous rupture of the common bile duct and huge retroperitoneal biloma was made by intraoperative abdominal exploration. The biloma was drained, ruptured portion of the common bile duct was primarily repaired over a T-tube.
Most common etiologic factors of the common bile duct ruptures are common bile duct stones and/or cysts, blunt or penetrating abdominal traumas, hepatobilliary operations and instrumentations . There are only few reports of spontaneous common bile duct rupture cases in literature and these cases are mostly infants or children due to congenital anomalies whereas it is exceedingly rare in adults -. There are also a few cases of spontaneous choledochus rupture described in pregnancy . Presentation of such patients is either insidious or acute. In acute cases, fulminant bile peritonitis with pain, vomiting, fever and abdominal distension is observed whereas painless abdominal distension, increasing jaundice and clay coloured stools are the main symptoms of patients presenting insidously. Here, we report a 38 years old female patient, presented with a complex cystic retroperitoneal mass as result of spontaneous common bile duct rupture due to chronic pancreatitis and successfully treated with surgical intervention.
No complication was observed during early follow-up. On the postoperative 10th day, the T-tube was withdrawn following a cholangiography which revealed a sufficient passage of contrast medium into the duodenum and no leakage out of the biliary tract. There was no abdominal pathology, except findings of chronic pancreatitis and dilatation of the common bile duct, at ultrasonography imaging performed 3 months after the operation.
The most common perforation site of biliary tract is the gallbladder, which is typically associated with cholecystitis and cholelithiasis . Spontaneous perforation of extrahepatic bile duct is an extremely rare condition which more often seen in infants and children. Among children, it is mostly due to common bile duct cysts, delivery traumas and pancreaticobiliary junction anomalies [4, 7, 8]. In adults, common bile duct ruptures are extremely uncommon conditions. Generally the etiologic reasons in adults are bile duct stones, which may increase the common bile duct pressure . Other ethiologic factors are biliary diverticulum  and acute pancreatitis . In a retrospective study of 11 cases of nontraumatic perforation of the common bile duct, Kang et al. reported that the primary diseases were common bile duct stones in 7, intrahepatic bile duct stones in 2, choledochal cyst and phytobezoar, each, in one of the cases .
Our case was subjected to cholecystectomy 8 years ago and neither common nor intrahepatic bile duct stones were found during the operation by either inspection and radiographically. Also, no evidence of any choledochal cyst or phytobezoar was explored during the operation. The only pathological finding was the calcification in the pancreas due to chronic pancreatitis, seen in the abdominal computed tomographic scan and this might be the cause of the stricture of the distal biliary duct which was observed in the cholangiography. We assumed that the increased ductal pressure in the common bile duct and the excessive friability of an oedematous common bile duct during the acute exacerbation of chronic pancreatitis, together may have led to perforation.
Written informed consent is obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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