362 Rare Case of Spontaneous Bile Duct Perforation Mimicking Appendicitis in an Adult: A Diagnostic and Therapeutic Insight

Abstract Introduction Spontaneous perforation of the bile duct (BD) is a rare cause of acute abdomen in adults. Pre-operative diagnosis is challenging due to its non-specific presentation and the rarity of the condition. Method We present a case of a 66-year-old female who presented with right iliac fossa (RIF) pain and clinical signs suggestive of acute appendicitis. Laboratory investigations revealed raised inflammatory markers and mildly deranged liver function tests. CT imaging suggested perforated appendicitis with a possible free fecalith in the RIF. Results No evidence of appendicitis, small bowel, duodenal or gastric perforation could be identified during laparoscopy. Laparotomy and further exploration, revealed a 3 mm perforation was on the anterior surface of the mid-BD. A T-tube was utilized for biliary drainage and repair, and right paracolic drain; no cholecystectomy was performed. Patient had an uneventful recovery, however, serial T Tube cholangiograms up to 4 months later showed subclinical leak. Therefore, the T-tube was removed during ERCP, and a self-expanding-metal-stent was deployed. The patient developed mild post-ERCP pancreatitis and is awaiting elective cholecystectomy. Conclusions This case highlights the diagnostic difficulties of spontaneous BD perforation in adults. Total laparoscopic management is feasible if BD perforation is suspected. The slow healing observed may suggest an underlying ischemic component. Optimal drainage is essential if slow healing is potentially expected post operatively. Should the gallbladder be routinely removed during initial intervention? Is the use of silicone T-tubes optimal, or would latex T-tubes—due to their greater inflammatory response—facilitate more rapid healing through fibrotic tract formation?