140 Spontaneous Perforation of the Common Bile Duct in the Absence of Choledocholithiasis: A Case Report

Abstract Introduction Spontaneous perforation of the common bile duct (CBD) is an uncommon clinical entity, typically reported in infants. In adults, it is usually secondary to impacted choledocholithiasis or biliary tract malignancy, with most perforations occurring in the extra-hepatic biliary system. Case Presentation We present a case of spontaneous extra-hepatic CBD perforation in an otherwise well woman in her seventh decade, with a background of COPD, hypertension, and Mounjaro therapy. She had no prior abdominal surgery or trauma. She presented with a short history of systemic upset, fever, and generalized peritonism. CT imaging revealed intra-peritoneal free fluid in the upper abdomen without pneumoperitoneum, and no clear source identified. Emergency diagnostic laparoscopy, converted to upper midline laparotomy, confirmed free bile was found, prompting conversion to laparotomy. The supra-duodenal CBD appeared bile-stained, raising suspicion of perforation. The lesser sac was clear. After abdominal washout and drain placement, she was transferred to intensive care. She was nursed in ITU. On day 4, Endoscopic Retrograde Cholangio-Pancreatography confirmed a leak at the junction of the cystic duct and CBD. No filling defects or strictures were noted. Biliary brushings were negative, and two plastic biliary stents were placed. She recovered uneventfully, with cessation of drain output and subsequent discharge home. Biliary brushings revealed no evidence of malignancy. Discussion Although rare, spontaneous CBD perforation should be considered in the differential diagnosis of bile peritonitis without obvious cause. Management principles align with those for iatrogenic bile leaks: early source control, sepsis management, biliary decompression, and multidisciplinary input are key to favourable outcomes.