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Spontaneous biliary tract perforations: an unusual cause of peritonitis in pregnancy. Report of two cases and review of literature
World Journal of Emergency Surgery
Spontaneous biliary tract perforations: an unusual cause of peritonitis in pregnancy. Report of two cases and review of literature
Nikhil Talwar 0
Manoj Andley 0
Bina Ravi 0
Ajay Kumar 0
0 Address: Department of Surgery, Lady Hardinge Medical College, University of Delhi , New Delhi-110001 , India
Spontaneous perforations of the biliary tract are rare in adults and even more so during pregnancy. Perforation of the gall bladder is a potentially fatal complication of cholecystitis. The infrequency of perforation in the setting of calculous disease of the gall bladder is probably due to the thickened wall of the organ that has long been the seat of chronic inflammation. Common bile duct perforations have been reported in adults most commonly in association with choledocholithiasis. The diagnosis of biliary tract perforations is often delayed due to their non specific symptoms, which results in high morbidity. Early diagnosis and aggressive therapy are mandatory to alleviate this condition. Delayed diagnoses and treatment may have more serious consequences for pregnant women than for other patients. Very few cases of biliary tract perforations have been reported in pregnant women. We report two such cases in pregnancy: first of a gall bladder perforation associated with cholelithiasis and the second of a common bile duct perforation in pregnancy in which no apparent cause was found.
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Background
The incidence of biliary tract disease during pregnancy
ranges from 0.05% to 0.3% [1]. Despite the rarity of the
condition, complications of gallstones represent the
second most common nongynecologic condition requiring
surgery in pregnancy after appendicitis [2]. The most
common indications for intervention for gall stones during
pregnancy include: obstructive jaundice, acute
cholecystitis failing medical management, and gall stone induced
pancreatitis [3]. Gall bladder perforation has been
reported to occur in 3 to 10% cases of acute cholecystitis
in adults; however, it has rarely been reported in
pregnancy [4]. Risk factors for gall bladder perforation in
adults include: age greater than 60 years,
immunosupression, steroid use, and severe systemic disease [4]. Since
this condition is unusual during pregnancy, accurate
diagnosis and treatment may be delayed resulting in perinatal
morbidity.
Spontaneous perforation of the common bile duct is a
rare event in adults, with only 40 cases having been
reported earlier [4]. Cholelithiasis, choledocholithiasis,
and tumor obstruction of the ampulla have been reported
as possible etiologies of perforation [5]. We report two
cases of spontaneous biliary tract perforations in
pregnancy, which were managed successfully. The clinical
presentations, radiological findings and management are
discussed.
Clinical presentation
Case 1
A 28-year-old gravida 2, para 1, 30 weeks pregnant
woman presented with sudden onset abdominal pain and
distension for two days. There was previous history of
right upper abdominal pain for six months, which got
relieved on analgesics. The previous pregnancy had been
uneventful. On physical examination, she was moderately
dehydrated and her temperature was 39.6C. Her pulse
was 110/minute, blood pressure was 90/60 mmHg and
there was no pallor or icterus. On abdominal
examination, there was generalized tenderness, guarding, rigidity
and rebound tenderness. Shifting dullness and fluid thrill
was present. The uterine fundal height corresponded to 30
weeks gestation. Bowel sounds were absent. Routine
laboratory tests revealed hemoglobin of 10.4 g/dL, total
leukocyte count of 18850 cells per mL. The blood sugar,
kidney and liver function tests were normal. The chest X
ray was normal and there was no free air under the
diaphragm. Abdominal sonography revealed bowel loops
floating in large amount of free fluid. A Single live foetus
of 30 weeks gestation was seen. Gall bladder with
multiple calculi and wall thickness of 4 mm was also noted.
Paracentesis yielded a free flow of purulent fluid admixed
with bile.
A clinical diagnosis of peritonitis due to bowel
perforation was made and the patient underwent an exploratory
laparotomy, which revealed about 4 litres of purulent
fluid inside the peritoneal cavity. A thorough exploration
revealed normal bowel. A gall bladder with multiple
stones and a perforation at the fundus was seen. A
cholecystectomy with peritoneal lavage was performed.
Postoperative course was uneventful and the patient was
discharged one week later. Histopathology of the gall
bladder was suggestive of acute cholecystitis. Her
pregnancy continued and at 37 weeks' gestation she vaginally
delivered a healthy baby. The patient is asymptomatic
after a follow up of three years.
Case 2
A 21-year-old primipara with 32 weeks pregnancy was
referred to us from the gynecology department with upper
abdominal pain and high-grade fever for 3 days associated
with abdominal distension. On examination, the patient
had a puls (...truncated)