Spontaneous Rupture of the Common Bile Duct IAN A. SPIRA, M.B., CH.B., F.R.C.S. (EDIN.), F.C.S. (SOUTH AFRICA) F.A.C.S.

From The Department of Surgery, Beth Israel Medical Center, Mount Sinai School of Medicine of the City University of New York, New York

Spontaneous rupture of the common bile duct is an extremely rare condition. Only 11 cases have been reported in the world literature. An unusual case of this complication is reported and the possible etiology and pathogenesis are discussed.

RUPTURE of the common bile duct unrelated to trauma,5'9-11 surgery3'4 or obstructing calculi is exceedingly rare. To date only 10 cases of this complica- tion and a left upper lobe lobectomy. The anesthetic agent used was tion have been reported in the literature (Table 1). We Halothane. Postoperatively, the patient's condition improved rapidly. However, wish to report a further case. a routine SMA 12 sent on the fourth postoperative day revealed the Case Report The patient, a 59-year old Puerto Rican man was admitted to the

hospital with a three-hour history of sudden onset of left-sided chest pain and dyspnea. He had been quite well prior to the onset of this pain. Physical examination revealed a well-built man who appeared older than his actual age. He was in mild respiratory distress. His pulse rate was 120 per minute and his blood pressure 130/100. Examination of the chest revealed a dorsal scoliosis and a left-sided pneumothorax. Examination of the abdomen revealed a palpable, firm liver two fingerbreadths below the right costal margin. X-ray of the chest revealed a left pneumothorax with complete collapse of the left lung (Fig. 1). A complete blood count was within normal limits and a Simultaneous Multiple Analysis (SMA) 12 on admission had the following results: Total bilirubin, 0.9 mgo; alkaline phosphatase, 76; serum glutamic oxaloacetic transaminase (S. G. 0. T.), 30; total protein, 7.0 G%; serum albumin, 4.4 G%; blood urea nitrogen, 16 mgo; serum cholesterol, 190 mg%o. The patient was admitted to the surgical ward and an intercostal chest tube was inserted on the left side and connected to an underwater drainage system. The patient's condition improved and 6 days after admission, x-ray of the chest revealing the left lung to have fully reexpanded, the chest tube was removed. Twelve hours later, the patient complained of a recurrence of the left-sided chest pain and dyspnea. Physical examination showed that the left pneumothorax had recurred and this was confirmed on chest x-ray. The chest tube was reinserted. The left lung, however, failed to completely re-expand, and 5 days later a second chest tube was inserted. Despite the presence of the two chest tubes, the patient continued to blow off air and the left lung remained partially collapsed. Therefore, on the 34th day of his hospital stay, the patient underwent a left thoracotomy, decorticaSubmitted for publication October 14, 1975. Reprint requests: Ian A. Spira, M.D., Beth Israel Medical Center, 10 Nathan D. Perlman Place, New York, New York 10003.

following significant results: Total bilirubin, 1.8 mg%; Alkaline phosphatase, 875 mgo; S. G.O. T., 340 mg%. It was felt that the patient might have developed hepatic necrosis secondary to the Halothane. By the tenth postoperative day the patient was deeply jaundiced. The liver function tests were: total bilirubin, 8.4 mg%; Alkaline phosphatase, 635 mgo; S.G.O.T., 160 mg%. Then on the 15th postoperative day, the patient complained of the sudden onset of severe abdominal pain associated with vomiting. General surgical consultation was sought. On examination, the patient appeared very ill. His pulse rate was 130 per minute and his blood pressure 100/70. Examination of the abdomen revealed board-like rigidity and rebound tenderness. A diagnosis of a perforated viscus with generalized peritonitis was made. The patient was rehydrated intravenously and a naso-gastric tube was passed. An emergency laparotomy was performed. At laparotomy a large amount of free bile was present in the peritoneal cavity. The gall bladder was collapsed and at the junction of the cystic duct with the common hepatic duct was a ragged perforation in the common bile duct about 0.5 cm. in diameter. There were no calculi palpable in the gall bladder. No masses were palpable in the common duct or duodenum. Because of the patient's poor general condition, it was thought advisable to do the minimum of mobilization and dissection. A biopsy was taken from the edge of the perforation and a T-tube was inserted into the common bile duct. The peritoneal cavity was laved with normal saline, a drain placed down to the common bile duct and the abdomen closed. Histologic examination of the edge of the perforation revealed the wall of the common bile duct with elements of acute and chronic inflammation (Fig. 2). Postoperatively, the patient's condition improved dramatically. The T-tube drained 1200 cc to 1500 cc of bile per day. The jaundice subsided and the liver enzyme values slowly returned to normal. On the 11th postoperative day a T-tube cholangiogram was performed which revealed gross dilatation of the biliary tree. The distal end of the common bile duct tapered to a point and no contrast material passed into the duodenum (Fig. 3). An upper gastrointestinal series

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TABLE 1. Collected Cases ofSpontaneous Perforation of the Bile Ducts

Author

Patient's Age

Spira

59

Hart7

43

Gans & Reydman6 Blegen & Boyer2

25 17

Verne'6 Reich'3 Taube & Himel'4 Newell'2 Wernsdorfer'7

54 73 30 63 40

Vale & Shapiro'5 Bailey' Lapenta8

23 45 69

Etiology Distal obstruction and infection Gangrene of wall of common bile duct Erosion of a calculus Diverticulum of common duct Erosion of a calculus Cirrhosis

Cyst Infection Diverticulum with infection Intramural infection Intramural infection Erosion of a calculus

Cholelithiasis Present Present Present Present Present Absent Present Present Present Present Present Present

was performed and this showed a filling defect on the medial wall of the duodenum in the vicinity of the Ampulla of Vater. The patient's general condition improved. He was orally hyperalimented and one month after the emergency laparotomy an elective abdominal exploration was performed. The T-tube was in place in a still dilated extra-hepatic ductal system. The liver was enlarged. Careful palpation of the gall bladder and common bile duct revealed no calculi and no tumors. However, when the duodenum was mobilized, a soft intraluminal mass could be palpated in the second portion of the duodenum. A duodenotomy was performed and a villous tumor, approximately 3.5 cm in diameter, was present on the medial wall of the duodenum overlying the Ampulla of Vater. The tumor was uniformly soft to palpation. The tumor was excised. Frozen section showed no evidence of malignancy. A cholecystectomy was performed and a choledochojejunostomy created in a Roux-en-Y fashion. On opening the gall bladder, three small calculi were discovered. The patient's postoperative course was uneventful and he was discharged on the 14th postoperative day. Histological examination of the

FIG. 2. Photomicrograph of tissue taken from the edge of the perforation in the common bile duct showing the loss of epithelium and evidence of acute and chronic inflammation.

excised tumor revealed the typical appearance of villous adenoma at the periphery (Fig. 4). However, the central portion showed evidence of invasive adenocarcinoma (Fig. 5).

Discussion

Spontaneous rupture of the common bile duct is an exceedingly rare condition and its occurrence has been attributed to a number of factors. Of the 11 reported cases, 10 had associated cholelithiasis. The only exception was the case reported by Reich'3 in which cirrhosis of the liver was implicated. Other factors thought to be contributory were: a) intramural infec-

tion,"'12"15 b) presence of a diverticulum in the common

.1

FIG. 3. T-tube cholangiogram showing gross dilatation of the biliary FIG. 1. Posteroanterior roentgenogram of the chest showing a left-sided ductal system. The distal end of the common bile duct appears totally obstructed. pneumothorax with collapse of the left lung.

VOl. 183 . NO. 4

RUPTURE OF THE COMMON BILE DUCT

435

FIG. 4. Photomicrograph of the excised villous tumor of the duodenum showing the characteristic pattem of the tumor.

FIG. 5. Photomicrograph of the excised villous tumor of the duodenum showing invasive adenocarcinoma.

bile duct,2 14'17 c) necrosis of the wall of the common bile duct secondary to thrombosis of the intramural vessels,7 and d) increased intraductal pressure secondary to some obstruction at the sphincter of Oddi. A combination of factors is probably responsible for rupture of the common bile duct. Erosion of a calculus through the wall of the duct is usually a slow process and is mainly associated with fistula formation. Further, complete distal obstruction results in an elevation of the intraductal pressure. In most cases this will only present itself as obstructive jaundice. However, if the wall of the bile duct has been weakened the raised pressure may precipitate a rupture. Infection plays an important role in the etiology of spontaneous rupture and, combined with the presence of calculi and/or a diverticulum is probably the important factor in causing weakness of the wall of the duct. Thrombosis of the intramural vessels probably follows on the infection. In the patient presented, there were three factors present which probably contributed to the occurrence of the rupture of the common bile duct. Firstly, there was the raised intraductal pressure due to the total obstruction at the distal end of the duct caused by the villous tumor in the duodenum. Secondly, calculi were present and thirdly, infection had supervened. No calculi were ever demonstrated in the common bile duct, only in the removed gall bladder. The edge of the perforation, however, did show evidence of acute and chronic inflammation and this combined with the distal obstruction was the probable cause of the rupture.

References 1. Bailey, H.: Emergency Surgery, 1: 103, Bristol Wm. Wood and Co., 1930. 2. Blegen, H. M. and Boyer, E. L.: Perforation of Choledochus Cyst with Biliary Peritonitis, Lancet, 66:117, 1946. 3. Brunschwig, A.: Postcholecystectomy Rupture of the Common Bile Duct, Surgery, 13:951, 1943. 4. Dreiling, D. A.: Spontaneous Rupture of the Common Bile Duct Following Choledocholithotomy, Surg. Clin. North Am., 27:381, 1947. 5. Fletcher, W. S., Mahnke, D. E. and Dunphy, J. E.: Complete Division of the Common Bile Duct Due to Blunt Trauma. Report of a Case and Review of the Literature, J. Trauma, 1:87, 1961. 6. Ganz, H. M. and Reydman, M.: Non-Traumatic Perforation of the Common Bile Duct. Am. J. Surg., 74:811, 1947. 7. Hart, D. E.: Spontaneous Perforation of the Common Bile Duct, Ann. Surg., 133:280, 1951. 8. Lapenta, V. A.: Perforation at the Juncture of Cystic and Common Ducts. Surg. Gynecol. Obstet., 20: 552, 1915. 9. Lee, J. G. and Wherry, D. C.: Traumatic Rupture of the Extrahepatic Biliary Ducts from External Trauma, J. Trauma, 1:105, 1961. 10. Mast, W. H. and Oz, H.: Complete Severance of the Common Bile Duct Due to External Blunt Trauma of the Abdomen, J. Internat. Coll. Surg., 34:726, 1960. 11. Neely, W. A. and Hardy, J. D.: Traumatic Severance of the Common Bile Duct: An Unusual Case, Am. Surg., 154:874, 1961.

12. Newell, E. D.: Spontaneous Rupture of the Common Bile Duct, Ann. Surg., 113:877, 1941. 13. Reich, N. E.: Spontaneous Rupture of Normal Hepatic Duct, Ann. Surg., 116:137, 1942. 14. Taube, H. N and Himel, H. A.: Non-Traumatic Perforation of Common Bile Duct., Am. J. Surg., 18:103, 1932. 15. Vale, C. F. and Shapiro, H.: Non-Traumatic Perforation of Common Bile Duct, Am. J. Surg., 18:103, 1932. 16. Verne, J. M.: Spontaneous Rupture of Hepatic Duct, Mem. Acad. Chir., 71:76, 1945. 17. Wernsdorfer, I.: Diverticulum of Choledochus with Succeeding Perforation. Zentralbl. P. Chir., 66:1141, 1939.

Spontaneous rupture of the common bile duct.

Spontaneous rupture of the common bile duct is an extremely rare condition. Only 11 cases have been reported in the world literature. An unusual case ...
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