Spontaneous Biliary Peritonitis in Children
A one-and-half-year-old male child presented with a 7-day history of fever, acholic stools, and vomiting and progressive abdominal distension for 3 days. Clinical examination revealed fever, icterus, abdominal distension, sluggish bowel sounds, tender hepatomegaly, guarding with rebound tenderness and fluid thrill. Total Leucocyte Count (TLC) was 17,000/dl with 83% neutrophils and Serum Bilirubin was 6.8 mg/dl. Ultrasound (USG) revealed ascites with dilatation of common bile duct (CBD), common hepatic duct (CHD), and intra-hepatic biliary radicals. Contrast Enhanced Computed Tomography (CECT) and Magnetic Resonance Imaging (MRI) confirmed the USG findings and also showed sudden tapering of distal CBD, distended gall bladder, peri-cholecystic fluid, and marked ascites. A disproportionately large fluid collection was seen in left posterior peri-hepatic space [Figures and ]. There was no evidence of pneumo-peritoneum. A provisional diagnosis of biliary perforation was made and the child was referred to a tertiary pediatric surgery centre, where abdominal paracentesis revealed bile. Two USG-guided pigtail drains were placed which drained nearly 800 ml of bile. The child was kept on antibiotics and nutritional support and subsequently taken up for definitive surgery. Exploratory laparotomy with adhesionolysis and cholecystectomy with Roux-en-Y hepatico-jejunostomy was performed []. The child recovered and has had an uneventful post-operative period over the last two years.