Spontaneous perforation of the biliary tract and the resulting bile peritonitis, though rare, are known to affect the extrahepatic biliary tract. The majority of these perforations occur in the gall bladder and are because of gallstones. Because of the rarity of the condition and lack of supportive investigations, preoperative diagnosis is usually not possible in most of the cases and diagnosis is only made at the time of laparotomy. We present a case with biliary peritonitis due to spontaneous rupture of the right hepatic duct in which the diagnosis was made on exploratory laparotomy.
Plain X-ray of abdomen did not show any evidence of pneumoperitoneum. Ultrasonography revealed a large amount of fluid collection with low-level internal echoes, septations, and loculations on the right side of the peritoneal cavity. The gall bladder was distended, grossly edematous and had moderate pericholecystic fluid. The intra-hepatic biliary radicles were normal, and the common bile duct (CBD) was obscured by bowel gas. Ultrasound-guided abdominal paracentesis was done, and it revealed bilious collection in the peritoneal cavity. Provisional diagnosis of peritonitis was made, and emergency exploratory laparotomy was planned and done.
Right hepatic duct was drained through perforation by T-Tube [ Figure 1 ] after checking the patency of ampulla. The right subhepatic space and pelvic region were drained. Postoperatively, recovery of the patient was good, and he was allowed orally on 2 nd day. On the 5 th postoperative day, bile started leaking in the abdominal drain. T-tube cholangiography was done to confirm the position of limbs inside the hepatic duct, and it was found to be well in place, but there was leakage of bile alongside the T-tube. The quantity of bile gradually decreased, and it stopped in about 3 weeks after the operation. T-tube was removed 4 weeks after the operation when cholangiogram was repeated and free passage of contrast inside the duodenum was confirmed [ Figure 2 ].
I wish to address the issue of diagnosis of pancreatic cancer. As consultant radiologist, I had valuable exposure to pancreatic cancer for over thirty years at St. George’s Hospital (SGH), which attracted a significant number of patients due to the pancreatico-biliary expertise of Mr. Knight and before him Lord Smith.
Regrettably I do not have exact figures to back me up but in my experience I would agree that pancreatic cancer not uncommonly presents with non specific symptoms, but my impression is that perhaps not as many presented through the Accident and Emergency Department. I also had the distinct advantage of clinicians relying largely on ultrasound scans for the diagnosis long before CT scans became the most important investigation (I was a trainee radiologist at Atkinson Morley’s Hospital on the SGH rotation when the first CT head scans were done).
It is uncontested that CT is now the most important investigation of pancreatic cancer and that ultrasound is less sensitive. Although sensitivity of ultrasound may not attain levels to equal that of CT, it is undoubtedly true that the sensitivity of ultrasound can be very significantly improved with improved technique and with minimum effort.
The need to improve the sensitivity is essential since ultrasound is often still the first investigation in patients presenting with abdominal pain, epigastric pain with or without jaundice. The symptoms may be often non specific. Consequently the patient may have an upper GI endoscopy, a colonoscopy and if these are negative patients are not uncommonly referred ‘to exclude gallstones’. A negative ultrasound particularly in the patients presenting with non specific symptoms may in a significant number of patients provide a false sense of security with no further investigations being undertaken: comments in the body of the report that the pancreas was ‘obscured by bowel gas’ is too often overlooked. But it can be a disaster waiting to happen, with the patient presenting a few months later with obstructive jaundice. I am not sure that failure to visualise the pancreas is worthy of highlighting in the conclusion if there is one. Should the radiologist highlight the need for further imaging or is it the responsibility of the clinician? Would it depend on whether pancreatic symptoms were included in the clinical details? Is there an accepted protocol?
The lack of sensitivity of ultrasound may be attributed to several causes. The expertise of the individual performing the ultrasound is highly variable and is probably the most important factor. Assignment of incompetent trainees to more or less unsupervised ultrasound lists in my opinion amounts to negligence on the part of those responsible for the training and is most unfair to the often unquestioning patient.
Poor scanning techniques and poor patient preparation contribute to the failure to visualise the pancreas.
One important factor contributing to this is the non fasting patients with significant gastric content specially when referred direct from the A & E department.
Although the turning the patients into the right and left anterior oblique (RAO and LAO) positions often improves the visualisation of the pancreas, the lower end of the common bile duct is best performed in the coronal plane with the patient supine and before being turned in to the RAO position. A plane similar to that used to demonstrate the IVC aorta and the para-aortic nodes. The RAO position often results in the fundal gas rising into the antrum and duodenum obstructing the view of the lower end of the CBD and its termination.
A drink of degassed water may help but is not often used.
Often the most useful manoeuvre is to scan the patient in the erect position and this seems to be rarely undertaken. I do not have figures but this improves visualisation when other manoeuvres have failed
It is my view that with improved techniques satisfactory visualisation of the pancreas is possible in over ninety five percent of patients.
Sadly a deplorable cause for failure is lack of trying hard enough, on the basis that this patient would invariably have a CT scan.
Criticism levelled at ultrasound is not the inadequacy of the modality, but the attitude of the user.
Ultrasound never lies.
Group includes those patients with obvious clinical jaundice or cholangitis with choledocholithiasis or a dilated CBD on ultrasonography.
Introduction: Common bile duct stone (CBDS) is a common clinical problem that can cause serious complications, such as acute cholangitis and pancreatitis. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of CBDS before proceeding to therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Objective: To compare the accuracy of trans-abdominal ultrasound (TAUS) as a diagnostic tool at our institution―Kurdistan Centre for Gastroenterology & Hepatology (KCGH)―with invasive tool like ERCP in the diagnosis of bile duct stones, using specificity, sensitivity, and positive and negative predictive values. Patient and Method: After obtaining ethical committee approval & informed consent from every patient. This was a prospective study conducted on 71 patients (24 male patients and 47 females patients) where suspected to have CBDS depending on history, clinical suspicion and blood tests. Their ages range between (2 – 88 years). Both TAUS and ERCP were performed. Final diagnosis was confirmed depending on ERCP as it served as a diagnostic standard in diagnosing CBDS. Result: In 71 patients suspected to have CBDS by TAUS, only 46 patients had stone (65%), and 55 patients had stone by ERCP (77%). In our result, sensitivity, specificity, positive predictive value and negative predictive value for TAUS were 80%, 87.5%, 65.5% and 56%, respectively. Conclusion: TAUS can play an important role as an initial screening procedure for CBDS detection because of the various advantages like easy availability, cost effectiveness, no requirement of contrast material and lack of ionizing radiation but should done with other imaging modality to avoid serious complication of ERCP.
Figure 9 . Ultrasound of dilated proximal CBD with impacted stone.