Spontaneous Biliary Peritonitis in Children
A 3-year-old male child presented with complaints of abdominal pain and high-grade intermittent fever, mild jaundice without cholestatic features, vomiting, and a lump in the right upper abdomen for 6-7 days. Initial imaging investigations, comprising of two sonograms were done elsewhere prior to admission at our center. First USG revealed large cystic area in the region of the gall bladder (GB) that was likely to be a distended GB/choledochal cyst. Second USG showed similar findings but suggested ruptured left liver lobe abscess as a differential as the cystic area was subjacent predominantly to the left lobe, alongwith presence of free fluid in right iliac fossa. The child had been started on antibiotics and anti-pyretics by a private clinician, which was continued even after his admission. However, USG-guided abdominal paracentesis from right iliac fossa revealed the presence of bile in the fluid collection. This led to a revised diagnosis of biliary perforation and subsequently a Computed Tomography (CT) scan was done []. It revealed hydrops of gall bladder (GB) with the neck of the GB going across the midline from right to left, crossing anterior to common bile duct and possibly compressing it, as there was dilatation of the right and left hepatic ducts and the common hepatic duct. There was no evidence of thickening of GB wall. A small collection of fluid was seen in the posterior left peri-hepatic space around the neck of GB along with some free fluid in right paracolic gutter, indicative of localized biliary perforation [Figure and ]. Hemogram revealed leukocytosis (TLC was 17300/dl and an elevated Serum Bilirubin level of 2.8 mg/dl.. The child was continued on conservative management. MRI of upper abdomen done about 7 days later [] showed reduction in diameter of GB from 5 cm to approximately 2.8 cm. Dilatation of hepatic ducts persisted with smooth transition in region of proximal CBD which was normal in caliber. Inflammatory stranding was seen in left sub-hepatic space with no free fluid. A diagnosis of hydrops of gall bladder with dilatation of central hepatic ducts and common hepatic duct and recovering biliary perforation was made. A follow-up MRI done a year-and-a-half later showed partially distended GB in similar location, and persisting dilatation of central hepatic ducts and common hepatic duct, which tapered smoothly into a normal caliber CBD [Figure and ]. The child improved with conservative management and is currently asymptomatic on follow-up investigation.