(P52) Golly! Is That a Gallbladder? Biliary Rupture on Ultrasound

Chief Complaint : vomiting and diarrhea

History of Present Illness : A 16 month old full-term female, up-to-date on vaccinations and without significant past medical history, presented with her mother for 5 days of NBNB vomiting and nonbloody diarrhea. Initially, there were intermittent episodes of abdominal pain, but that seemed to subside when the diarrhea stopped; however, multiple episodes of vomiting continued to occur daily. She was seen one day prior at an outside ED and was given Zofran and discharged. However, soon after discharge she worsened again, experiencing several more episodes of emesis. After one episode, the patient appeared to lose consciousness, then awoke again and vomited, prompting mother to bring her to the ED. No seizures, difficulty breathing or cyanosis were noted. Patient’s mother also denied fevers, sick contacts, or recent travel.

Pertinent Physical Exam: Vitals: T 37.3° C (99.1° F), HR 159, RR 44, BP 91/69, SpO2 100% on room air
General: thin, weak, ill-appearing but nontoxic, listless but occasionally irritable
Skin: warm, dry, no rashes or lesions
HEENT: dry mucous membranes, sunken eyes
Cardiovascular: tachycardic, regular rhythm, no murmur, bilateral radial pulse +2, capillary refill < 2 seconds
Respiratory: lungs clear to auscultation, breath sounds equal, tachypnea without significant accessory muscle use
Gastrointestinal: soft, nontender to palpation, non-distended

Pertinent Laboratory Data: BMP: Na 138, K 3.7, Cl 102, HCO3 21, Creatinine 0.32, BUN 10, glucose 291*, anion gap 15*
CBC: WBC 20.0*, RBC 4.60, Hgb 12.4, HCT 37.6, MCV 81.8, Plt 377
Hepatic: ALT 157*, AST 173*, GGT 369*, total bilirubin 1.3*, direct bilirubin 0.6*, albumin 4.1, protein 5.9
Lactic acid 1.2
Hgb A1c 5.5

Case Discussion: Histologically, an edematous gallbladder wall resulting in a matrix like structure is a result of the mucosal, muscular, and serosal layers absorbing fluid when there is surrounding free fluid. A broad differential exists for an edematous gallbladder wall.

Our patient suffered a spontaneous rupture of her hepatic duct. Surgical consultation, CT scan, HIDA scan, and diagnostic laparoscopy with intraoperative cholangiogram are necessary. It is a rare phenomena, but with bedside ultrasound evaluation and early surgical consultation, prognosis is generally good.

Hospital course: The patient was found to have a large amount of free fluid in her peritoneal cavity associated with the contracted gallbladder and edematous gallbladder wall. Surgery was consulted, and a CT scan was done, which redemonstrated the ultrasound findings; however, no clear source of the free fluid was found. Thereafter, a HIDA scan was performed, which was concerning for bile leak, and the patient was taken to the OR for diagnostic laparoscopy. Intraoperative cholangiogram revealed a common hepatic duct rupture. Biliary drains were placed, and the patient was transferred to the PICU for further care; she was discharged on hospital day 23.

Discussion of etiology: Spontaneous rupture of the bile ducts is an exceedingly rare occurrence thought to be caused by a combination of factors, including erosion of the wall in the presence of a calculus, weakening of the wall in the setting of infection, and raised intraductal pressure due to stasis, which together may precipitate rupture. In this patient without evidence of mechanical obstruction, it is possible that acute illness contributed to ductal wall weakening, with biliary stasis thereafter causing rupture. It is possible also that abnormal anatomical variation played a contributing role, though intraoperative imaging did not definitively answer this question.

References and Acknowledgements (Optional): Jeanty, C., Derderian, S. C., Hirose, S., Lee, H., &; Padilla, B. E. (2015). Spontaneous biliary perforation in infancy: Management strategies and outcomes. Journal of Pediatric Surgery, 50(7), 1137–1141. https://doi.org/10.1016/j.jpedsurg.2014.07.012

Housset, C., Chrétien, Y., Debray, D., & Chignard, N. (2016). Functions of the gallbladder. Comprehensive Physiology, 1549–1577. https://doi.org/10.1002/cphy.c150050

Blanco, P., & Volpicelli, G. (2016). Common pitfalls in point-of-care ultrasound: A practical guide for emergency and critical care physicians. Critical Ultrasound Journal, 8(1). https://doi.org/10.1186/s13089-016-0052-x

Gupta, A., Sunil, K., Verma, A. K., Singh, A. K., Kureel, S. N., & Pandey, A. (2018). Spontaneous common hepatic duct perforation in a child: A rare case report. African Journal of Paediatric Surgery, 15(1), 53. https://doi.org/10.4103/ajps.ajps_74_17