Hindawi Publishing Corporation
Volume 2008, Article ID 174202, 3 pages
Gallstone-Induced Perforation of the Common
Bile Duct in Pregnancy
N. Dabbas,1M. Abdelaziz,1K. Hamdan,1B. Stedman,2and M. Abu Hilal1
1Department of Surgery, Southampton General Hospital, Tremona Road, Southampton,
Hampshire SO16 6YD, UK
2Department of Radiology, Southampton General Hospital, Tremona Road, Southampton,
Hampshire SO16 6YD, UK
Correspondence should be addressed to M. Abu Hilal, abu email@example.com
Received 9 January 2008; Revised 26 April 2008; Accepted 17 June 2008
Recommended by Guy Maddern
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.
Copyright © 2008 N. Dabbas et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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 .
Bile duct perforation is most commonly described in
infants related to congenital biliary system anomalies. Aeti-
ology 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 .
The incidence of biliary tract disease during pregnancy
ranges from 0.05–0.3% . Despite these apparent low
figures, complications from gallstones represent the most
common general surgical condition requiring surgical inter-
vention, second only to appendicitis . Indications for
intervention of gallstonesduring pregnancy include obstruc-
tive jaundice, acute cholecystitis, or pancreatitis failing
diagnosed with gallstones in late pregnancy, complicated by
acute gallstone pancreatitis and subsequently spontaneous
common bile duct perforation.
A twenty-year-old primigravida woman was planned for
elective caesarean section due to breech presentation. The
patient had a past medical history of α-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
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
1369IU/L [36–128]), mildly raised bilirubin (24μmol/L [0–
20]) and raised alkaline phosphatase (183IU/L [35–91]). An
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 abdom-
inal pain. She was pyrexial (39.3◦C), tachycardic, and
hypotensive. Abdominal examination revealed severe gener-
2 HPB Surgery
Figure 1: Postoperative T-tube cholangiogram illustrating normal
duodenal filling with no visible bile duct filling defect.
emergency caesarean section was performed and a term baby
delivered, but no obvious cause was found to explain her
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 2mm perforation was found
on the anterior surface of a dilated common bile duct
(12mm). On table cholangiography suggested obstruction
of the distal common bile duct caused by a 5mm 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 (Figure 1).
Although the pathogenesis of spontaneous biliary perfora-
tion 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
of cholelithiasis, the diagnosis should be suspected if a
perihepatic abscess or peritonitis is combined with biliary
As early as 1882, Freeland  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.  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.  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
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 pre-
cipitating cause. McGrath et al.  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
Several reports exist of successful laparoscopic cholecys-
tectomy during pregnancy. Block and Kelly  reported
the optimum time for surgical management of gallstone
period, in order to minimise maternal/fetal mortality and
Unfortunately, in those women presenting late in preg-
nancy (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 sphinc-
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
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
N. Dabbas et al.3 Download full-text
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
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