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.