Case Presentation
A 40-year-old fit black African farmer was admitted as an emergency with
a 3-week history of gradual onset epigastric pain which was burning in
nature, constant and radiated to the back and chest. There were no
exacerbating or relieving factors. He had recurrent abdominal pain in
the past 6 years which was managed conservatively. On this occasion he
complained of fever and there was jaundice with a dark urine but no pale
stool. He had no relevant past medical history nor risk factors for
chronic liver disease. On examination, he had a blood pressure of 153/92
mmHg, heart rate of 81 beats/min, respiratory rate of 22 breaths/min and
a temperature of 37.20 C. He had an icteric sclera and
a tender right hypchondrial mass with a positive Murphy’s sign
consistent with an acute cholecystitis. An abdominal ultrasound scan
demonstrated an acute cholecystitis with a distally impacting CBD stone.
A full blood count and renal function tests were normal. Hepatitis and
HIV screen were negative. Liver function tests showed an obstructive
picture with raised alkaline phosphatase 763.52ui/l (n: 38-126ui/l),
ALAT 80ui/l ( n: 0-41), ASAT 32ui/l (n: 0-42). Following resuscitation
with Intravenous fluids , broad spectrum antibiotics and intramuscular
vitamin K , he consented to a cholecystectomy and a transduodenal
sphincterotomy/plasty. At operation, there was an acutely inflamed,
intrahepatic, gangrenous gallbladder impacting on the CBD. There was no
palpable gallbladder nor common bile duct stone and, the CBD was not
dilated. As the patient was unstable anaesthetically, the decision for a
staged approach was made to initially treat the gallbladder sepsis
followed by post-operative observation for the possible spontaneous
passage of the distal CBD stone, or the exploration of the CBD if the
patient remained symptomatic. A difficult retrograde cholecystectomy was
performed. On the 9th post operative day he developed basal pneumonia
which was treated aggressively with intravenous antibiotics, oxygen
therapy and chest physiotherapy. On the 20th post
operative day there was a sudden biliary leakage via the healing midline
abdominal wound. A contrast computed tomography (CT) scan revealed a
voluminous right hypochondrial and perihepatic peritoneal purulent
collection measuring 682 cc and, an impacted calculi at the base of the
CBD. The pancreas was normal. A difficult emergency laparotomy revealed
severe biliary leak from the dehisced cystic duct stump with dense
adhesions. This was doubly resutured with 2.0 vicryl. Full Kocherisation
of the duodenum, allowed the upper aspect of the duodenum (duodenal
bulb) to lie comfortably against the dilated CBD. This changed our
decision from performing a transduodenal sphincterotomy/plasty to a more
straight forward bypass procedure (a cholechoduodenostomy or a
hepaticoduodenostomy). Because of the inflamed cystic duct stump and
adhesions surrounding the CBD, we opted for a more proximal approach in
a hepaticoduodenostomy. A vertical incision was made in the CHD, and a
longitudinal incision made in the adjacent duodenum which was then
sutured transversely. This side- to side anastomosis was performed in a
one layer of continuous sutures of 3/0 absorbable material (vicryl). At
completion the anastomosis was diamond- shaped with a stoma diameter of
at least 2.5 cm. Following this procedure, a T-tube drainage of the CBD
was not necessary. A sub-hepatic drain was inserted. The surgery was
complicated by severe biliary leak from the anastomosis which subsided
in about 2 weeks. The symptoms of jaundice, pain and fever resolved and
the patient was discharged a month after the initial operation. But for
the patient’s financial difficulties, a follow-up contrast CT scan was
planned to assess the nature of the extrahepatic biliary tree and
ascertain if the calculi had spontaneously passed.