S3416 Bile Peritonitis: A Post-Cholecystectomy Nightmare Secondary to Periportal and Peripancreatic Varices

Introduction: Bile peritonitis is a rare, severe complication resulting from bile leakage into the peritoneal cavity, typically following biliary trauma or surgery but also possible from spontaneous duct perforations or injuries. This condition is associated with a high mortality, ranging from 8%-40%. Few cases have been reported secondary to mass effect and in relationship to vascular abnormalities such as varices. Case Description/Methods: A 47-year-old man with liver cirrhosis complicated by portal hypertension, recently hospitalized for sepsis due to perforated cholecystitis status post open cholecystectomy with JP drain removal, presented to the emergency department with severe right upper quadrant pain radiating to the shoulder. On arrival, he was hemodynamically stable, but physical examination revealed an acute abdomen. Laboratory findings showed a total bilirubin of 4.3, leukocytosis, and acute kidney injury. An abdomino-pelvic computed tomography scan demonstrated air and fluid in the gallbladder fossa and complex right upper quadrant soft tissue changes. A hepatobiliary iminodiacetic acid scan confirmed a bile leak, prompting urgent surgical intervention and intensive care unit admission, where he was started on broad-spectrum antibiotics. Exploratory laparotomy (ex-lap) on day 2 revealed 5 liters of old blood in the abdomen and a disrupted bile duct caused by mass effect from bleeding peri-portal and peri-pancreatic varices. A wound vacuum was placed in the open abdomen for follow-up Roux-en-Y hepatico-jejunostomy and abdominal washout, which was performed 2 days later. A subsequent ex-lap with drain placements and abdominal closure with wound vac placement followed. After a normal upper gastrointestinal series, the patient’s diet was advanced as tolerated. He was safely discharged to inpatient rehabilitation with close follow-up. Depicts computed tomography abdomen findings 5 days after discharge. Discussion: This case highlights the importance of early recognition of bile peritonitis with prompt intervention. This is crucial to avoid progression to generalized peritonitis, sepsis, or multi-organ failure. The high mortality rate associated with this condition, should raise awareness for a low threshold for suspicion specially after surgical manipulation of biliary structures. In this specific scenario, keeping in mind liver cirrhosis as a comorbidity that puts patients at risk for varix formation alongside the biliary vasculature it’s important to recognize mass effect as a cause of bile duct damage and subsequent leak.