141 Spontaneous Intrahepatic Bile Duct Rupture During Pregnancy

Abstract Background Spontaneous intrahepatic bile duct rupture is a rare but serious cause of biliary peritonitis. Most reported cases involve children with choledochal anomalies or adults with obstructive biliary pathologies. Pathogenesis remains poorly understood, but increased intraductal pressure and ischaemia are likely contributors. Ruptures often occur in hepatic segment IV, due to its superficial location and susceptibility to pressure changes. In pregnancy, symptoms may mimic obstetric emergencies, often delaying diagnosis and management. Case Presentation A 22-year-old woman at 36 weeks’ gestation with known gallstones presented with severe abdominal pain and foetal distress. Emergency Caesarean section was performed for suspected placental abruption. Intraoperatively, brown-green fluid was seen in the pelvis, presumed by the obstetric team to be secondary to endometriosis. A drain was placed, and no further action taken. Postoperatively, the patient developed fever, tachycardia, and raised inflammatory markers. High drain bilious output prompted surgical review. CT showed a large amount of free fluid, a segment 4b liver collection, and a left portal vein thrombosis. Laparoscopy showed a normal gallbladder and duodenum but identified a biloma with active bile leak from a ruptured intrahepatic duct. The duct was sutured and the biloma drained. ERCP confirmed no distal obstruction or further leak. The patient recovered well and underwent elective cholecystectomy three months later. Conclusions This case illustrates the diagnostic challenge of rare biliary pathologies in pregnancy. Awareness of this rare entity is important not only for surgeons but also for obstetric team, as timely recognition and surgical intervention are critical.