Atwez Abdelaziz, Augustine Matthew, Nottingham James M
University of South Carolina, School of Medicine, Department of Surgery, Two Medical Park, suite 306 Columbia, SC 29203, USA.
University of South Carolina, School of Medicine, Department of Surgery, Two Medical Park, suite 306 Columbia, SC 29203, USA.
Int J Surg Case Rep. 2017;41:188-190. doi: 10.1016/j.ijscr.2017.10.023. Epub 2017 Oct 18.
Non-traumatic biliary perforation other than the gallbladder is extremely rare and most commonly seen in children in association with congenital biliary anomalies. We present a rare case of choledocholithiasis that progressed to spontaneous perforation of the common hepatic duct probably from ischemic necrosis caused by impaction of large biliary stones.
A 62-year-old female presented with diarrhea and jaundice. She was found to have two 2.5cm stones in the common hepatic duct. Stones could not be extracted by ERCP, and placement of biliary stent was done to restore patency. The patient was lost to follow up and returned after three months with a new onset of similar symptoms. At that time ERCP and a stent change were done without resolution of the symptoms. Patient then underwent an open exploration and was found to have a free perforation in the lateral aspect of the common hepatic duct just at the bifurcation of the right and left hepatic radicals. Through this perforation stones were both extracted and cholangiogram showed free flow with the distal biliary stent. The stent was nowhere near the site of perforation which appeared to be caused by pressure necrosis from the impacted stones.
Impacted stones in the biliary tree need to be extracted to avoid pressure necrosis and spontaneous perforation. ERCP and stent placement should be used only as temporizing measures to manage the acute obstructive phase. Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones and avoid complications.
除胆囊外的非创伤性胆管穿孔极为罕见，最常见于儿童，且常与先天性胆管异常相关。我们报告一例罕见的胆总管结石病例，该病例可能因大的胆管结石嵌顿导致缺血坏死，进而发展为肝总管自发性穿孔。
一名62岁女性因腹泻和黄疸就诊。发现其肝总管内有两颗2.5厘米的结石。经内镜逆行胰胆管造影术（ERCP）无法取出结石，遂放置胆管支架以恢复通畅。患者失访，三个月后因类似症状再次就诊。此时再次进行ERCP及更换支架，但症状仍未缓解。随后患者接受了开放探查，发现肝总管在左右肝管分支处的外侧有一个游离穿孔。通过该穿孔取出了结石，胆管造影显示远端胆管支架通畅。支架与穿孔部位相距甚远，穿孔似乎是由嵌顿结石的压迫坏死所致。
胆管树内的嵌顿结石需要取出，以避免压迫坏死和自发性穿孔。ERCP及支架置入仅应用于处理急性梗阻期的临时措施。在初始胆管减压后，必须进行确定性手术干预以取出嵌顿的胆管结石并避免并发症。
