# Gallstone-Induced Perforation of the Common  Bile Duct in Pregnancy

Authors: N. Dabbas; M. Abdelaziz; K. Hamdan; B. Stedman; M. Abu Hilal
Journal: HPB Surgery
 (2008)

---

## Abstract

Spontaneous perforation of the extrahepatic biliary system is a rare presentation of ductal stones. We report the case of a twenty-year-old woman presenting at term with biliary peritonitis caused by common bile duct (CBD) perforation due to an impacted stone in the distal common bile duct. The patient had suffered a single herald episode of acute gallstone pancreatitis during the third trimester. The patient underwent an emergency laparotomy, bile duct exploration, and removal of the ductal stone. The postoperative course was uneventful.


---

## Body

## 1. Introduction

Perforation of the biliary system occurs
most frequently in the gallbladder, usually associated with (and complicating
upto 10 % cases of)   acute cholecystitis. Perforation of the extrahepatic biliary
tree is a rare entity, accounting for less than 10 % of intraperitoneal biliary
rupture [1].Bile
duct perforation is most commonly described in infants related to congenital
biliary system anomalies. Aetiology in the adult is commonly attributable to
intramural infection, necrosis of the wall of the bile duct secondary to
thrombosis, increased intraductal pressure secondary to obstruction, cirrhosis,
and direct erosion by calculi. Overall, 70 % of cases are related to calculi
[2].The
incidence of biliary tract disease during pregnancy ranges from 0.05–0.3 % [3]. Despite
these apparent low
figures, complications from gallstones represent the most common general surgical condition
requiring surgical intervention, second only to appendicitis [4]. Indications for intervention of gallstones during pregnancy
include obstructive jaundice, acute cholecystitis, or pancreatitis failing
medical management. We present the case of a young woman diagnosed with
gallstones in late pregnancy, complicated by acute gallstone pancreatitis and
subsequently spontaneous common bile duct perforation.


## 2. Case Presentation

A twenty-year-old primigravida woman was
planned for elective caesarean section due to breech presentation. The patient
had a past medical history ofα-Thalassemia trait, but was not
normally on regular medication. Her mother had previously undergone a
cholecystectomy for gallstones.At 34 weeks gestation, she presented
acutely with a two-week history of worsening abdominal pain localised to the
epigastric region, associated with vomiting. On examination, tenderness was localised to the epigastrium and right upper quadrant. Blood
results revealed raised inflammatory markers (WBC 14.4 [4.0–11.0],
neutrophils 11.9 [2.0–7.5], CRP 60
[0–7.5]) and evidence of pancreatitis (amylase 1369 IU/L [36–128]), mildly
raised bilirubin (24μmol/L [0–20]) and raised alkaline phosphatase (183 IU/L
[35–91]). An abdominal ultrasound revealed multiple small gallstones and a
thickened gallbladder wall, but no evidence of a dilated intra or extrahepatic
biliary system. The patient was treated conservatively, rapidly improved, and liver function tests
normalised. She was discharged three days later.Six
weeks later, she was readmitted with severe abdominal pain. She was pyrexial
(39.3°C),
tachycardic, and hypotensive. Abdominal examination revealed severe generalised
abdominal tenderness with evidence of peritonism. An emergency caesarean
section was performed and a term baby delivered, but no obvious cause was found
to explain her clinical condition.The
following day her clinical condition worsened, with progressive abdominal pain
and a metabolic
acidosis. She required aggressive resuscitation, inotropic, and ventilatory support and was,
therefore, admitted to the intensive care unit. A computed tomography (CT)
revealed extensive free peritoneal fluid and gas of which the aetiology was not
apparent. The patient underwent a prompt laparotomy and was found to have
generalised biliary peritonitis. The gallbladder was intact but a 2 mm
perforation was found on the anterior surface of a dilated common
bile duct (12 mm). On table cholangiography suggested obstruction of the distal
common bile duct caused by a 5 mm gallstone impacted within the distal common
bile duct.
The calculus was removed, and the duct was repaired over a T-tube. Repeat
cholangiography showed no residual obstruction. The patient had an uneventful postoperative recovery and was
discharged on day seven. A T-tube cholangiogram was performed
after 4 weeks, and the tube was uneventfully removed (Figure1).Figure 1
Postoperative T-tube cholangiogram
illustrating normal duodenal filling with no visible bile duct filling defect.


## 3. Discussion

Although
the pathogenesis of spontaneous biliary perforation is poorly understood,
recognised mechanisms include the following: calculous perforation at the site
of impaction; calculous erosion without impaction; increased canalicular
pressure due to obstruction by tumour, stone, or spasm of the sphincter of
Oddi; intramural infection; mural vessel infarction leading to mural necrosis;
or rupture of a biliary tract anomaly such as cyst or diverticulum [5]. Thus,
because perforation of the biliary system is a recognised complication of
cholelithiasis, the diagnosis should be suspected if a perihepatic abscess or
peritonitis is combined with biliary stone disease.As
early as 1882, Freeland [6] reported the first case of extrahepatic biliary
system rupture in an adult (diagnosed at autopsy), an entity that was
subsequently first described in pregnancy by Piotrowski et al. [2] over a
century later. Since this time, very few cases of spontaneous common bile duct
perforation in adults have been reported in the literature, with cases
occurring during pregnancy being even more scarce. The importance of this clinical
scenario lies in the potential serious morbidity and not infrequent mortality
associated with missed biliary system perforation.Petrozza
et al. [7] described two cases of gallbladder perforation due to cholelithiasis in
the early postpartum period. Both cases presented a diagnostic dilemma, and it
was concluded that a history of cholelithiasis in a patient with persistent
intra-abdominal symptoms in the postpartum period must alert to prompt
investigation and early management. Talwar et al. [8] report two
cases of biliary tract rupture under similar circumstances. In their series,
one patient was found to have suffered gallbladder rupture as a result of
cholecystitis, and in the second, a common bile duct perforation was found at
laparotomy with no obvious precipitating cause. McGrath et al. [9] also drew
attention to the similarity of symptoms of gallbladder disease in pregnancy to
mild pre-eclampsia, having in common hypertension, epigastric pain, and mildly
deranged liver function tests. These cases highlight the importance of
recognising the possibility of delayed diagnosis of cholelithiasis as a result
of nonspecific abdominal symptoms during pregnancy and indicate early
investigation and treatment in order to reduce serious morbidity.Several
reports exist of successful laparoscopic cholecystectomy during pregnancy.
Block and Kelly [10] reported the optimum time for surgical management of
gallstone pancreatitis to be in the second trimester or early postpartum
period, in order to minimise maternal/fetal mortality and recurrent
pancreatitis.Unfortunately, in those women presenting
late in pregnancy (as in the case described), the balance of risk favours
watchful waiting until after delivery followed by elective cholecystectomy.
Certainly, this risks early recurrence of acute pancreatitis, as well as rare but severe
consequences such as biliary peritonitis.
Whether an early endoscopic retrograde cholangiopancreaticography (ERCP)
and sphincterotomy in those cases presenting with gallstone pancreatitis can be
an acceptable temporary preventive measure is unclear, but undertaking ERCP is
not without risk, and the potential risks should be considered carefully in
individual cases. In this particular case,
it is impossible to know whether the eroding calculus had been present during the
initial episode of pancreatitis. Magnetic resonance scanning is a commonly used
imaging modality in obstetrics, considered to be safe and avoiding the use of
ionising radiation. Therefore, magnetic resonance cholangiopancreatography
(MRCP) would have been a reasonable next investigation during this patient’s
initial presentation, and if a ductal stone had been revealed, then the indication
for ERCP may have been clearer.On the other hand, neonatal and postnatal
care of babies born early have progressed significantly, suggesting the
possibility of induction of labour perhaps at 36–38 weeks
gestation in severely symptomatic or high-risk patients. Of course, every case
must be considered individually, taking into account maternal and fetal
history and health.



---

*Source: 174202-2008-06-30.xml*