A 62-year-old man had a past history of cirrhosis of the liver and placement of a plastic biliary stent 18 years earlier, secondary to choledocholithiasis. He arrived at the emergency room with diffuse abdominal pain, abdominal distension, jaundice, and fever.
In the initial evaluation, the laboratory work-up reported hemoglobin 10.5 g/dL, platelets 173 × 103/μL, leukocytes 44.4 × 103/μL, total neutrophils 92%, INR 2.13, glucose 46.3 mg/dL, creatinine 2.42 mg/dL, total bilirubin 17.89 mg/dL, direct bilirubin 10.87 mg/dL, indirect bilirubin 7.02 mg/dL, alkaline phosphatase 347.6 U/L. Plain abdominal x-ray showed a radio-opaque image in the right upper quadrant (Fig. 1). A non-contrast abdominal computed tomography scan showed a 16 cm craniocaudal lobe of the liver with a homogeneous parenchyma (Fig. 2), and intrahepatic and extrahepatic bile duct dilation. In the common bile duct, a 65 × 19 × 19 mm oval-shaped, hypodense image was identified, with well-defined edges, consistent with a large biliary stone surrounded by perilesional air (Fig. 3).
A) Non-contrast abdominal computed tomography scan, coronal view, showing a hyperdense artifact (arrow), with duodenal wall thickening and periduodenal gas. B) Non-contrast abdominal computed tomography scan, sagittal view, showing a hyperdense artifact (arrow), with gas dissecting into the retroperitoneum.
Exploratory laparotomy revealed 300 cc of bile in the peritoneal cavity, a perforation of 1 cm in diameter on the lateral surface of the second part of the duodenum, secondary to migration of the plastic endostent (Fig. 4), three-fourths of which was covered by a biliary stone (Fig. 5). A Stone triple-tube-ostomy was performed, as damage-control surgery. The patient’s postoperative clinical course was favorable.
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The authors declare that there is no conflict of interest.
