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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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Case Report

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Diagnostic Dilemma in an Unusual Case of Common Bile Duct Obstruction

Vimal Bhandari*, Mohit Singh, Hari Gopal Vyas, Nitin Sharma, and Rajkumar Chejara

Department of Surgery, Vardhaman Mahavir Medical College and Safdarjang Hospital, New Delhi, India.

Correspondence to: Vimal Bhandari. Department of Surgery, Vardhaman Mahavir Medical College and Safdarjang Hospital, D II/24 East Kidwai Nagar, New Delhi 110-023, India. Tel: +91-9899027348, Fax: +91-1126191877, mohitsingh24@gmail.com

Received: March 12, 2010; Accepted: May 19, 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2011;5(2):245-247. https://doi.org/10.5009/gnl.2011.5.2.245

Published online June 23, 2011, Published date June 30, 2011

Copyright © Gut and Liver.

Biliary obstructions are rarely caused by a foreign body and have received sparse attention. We present an unusual case with pruritis and abdominal pain caused by impacted full length surgical gauze within the common bile duct. The patient had previously undergone an open cholecystectomy. Radiological investigations were inconclusive and suggestive of either a calculus or a cholangiocarcinoma. Surgical exploration revealed full length surgical gauze within the common bile duct. Because imaging modalities are often non-determinant, the possibility of biliary tract obstruction from a foreign body should be borne in mind for patients with unusual presentations, especially those who have previously undergone surgery.

Keywords: Foreign body, Bile duct obstruction

Obstructive jaundice is commonly caused by a stone or growth in common bile duct (CBD). Foreign bodies in the biliary tract like sutures,1 fish bone,2 tomato skin,3 surgical gauze,1,4,5 and chicken bone6 represent an uncommon clinical entity and are rare cause of biliary obstruction.1,4 However with recent advancements in endoscopic and laparoscopic surgery an increasing number of impacted foreign bodies like endoclips have been reported.1 The previous reported cases with impacted surgical gauze in CBD had classical presentation of obstructive jaundice.1,4,5 We report a unique case of 45-year-old female who presented with abdominal pain and itching caused by surgical gauze impacted in the biliary tree without any clinical evidence of jaundice and cholangitis.

A 45-year-old female presented to out patient clinic with complaints of severe itching and occasional attacks of abdominal pain for past 2 to 3 months. She had undergone open cholecystectomy 10 years back however no operative details of the procedure were available. Physical examination was unremarkable except for itch marks over the abdomen and operative healed scar with primary intention in the right subcostal region. No lump was palpable on per abdomen examination. Laboratory parameters demonstrated leukocyte count 8,700/cu.mm, serum alkaline phosphatase 806 IU/mL, total serum Bilirubin 1.4 mg/dL with conjugated fraction 1.0 mg/dL. Ultrasonography of the abdomen showed dilated intrahepatic biliary radicals (IHBR) and dilated common hepatic duct with an echogenic structure of 36×33 mm size in the proximal bile duct with post-acoustic shadow suggestive of a calculus. Magnetic resonance cholangiopancreatography (MRCP) also revealed marked dilatation of the IHBR and hepatic duct with signal void lesion in the distal CBD (Fig. 1). A heterogeneous mass was seen within CBD extending proximally towards the porta hepatis suggesting possibility of cholangiocarcinoma arising from the hepatic duct. Computed tomography was inconclusive and could not define the cause of obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted but cannulation failed. A differential diagnosis of calculus with secondary cholangiocarcinoma was made and exploratory laparotomy was planned. On surgical exploration no obvious growth or lymph nodes were seen. A soft to firm structure was palpable within the CBD and the hepatic ducts. Choledochotomy revealed full length surgical gauze lying within the proximal CBD and common hepatic duct extending into the right hepatic duct (Fig. 2). The gauze was removed and CBD was closed over a T-tube. Gross examination of the retrieved gauze revealed staining with bile and few concretions. Cholangiogram performed on 14th post operative day revealed free flow into the duodenum. Patient had an uneventful postoperative course and was discharged subsequently. She remained free of symptoms on follow up at 3 months.

Biliary obstruction due to foreign bodies are uncommon and have been rarely described.1-8 Ban et al.7 reviewed the literature and found 63 patients of foreign objects in the biliary tract. Majority of these cases presented with biliary colic and jaundice was present in 46% of the patients. Commonly encountered foreign bodies included residuals from previous operations, mostly a suture ligature acting as a nidus for stone formation. Others included missiles and ingested materials. Penetrating injuries (missiles) usually present with a long symptom free period.7,8 There is documented susceptibility to reflux of food into the biliary system and foreign bodies like fish bone and tomato skin2,3 have been retrieved in patients with enteric-biliary anastomosis or those who had endoscopic sphincterotomy. Recently with increase in laparoscopic cholecystectomy, foreign bodies like clips have also been reported within the biliary tract.6 Roentogenologic investigations are usually unrewarding. Plain X-rays of abdomen have revealed foreign bodies in only a few cases and correct diagnosis was not possible in majority.7 Ultrasonography and MRCP findings are also inconclusive in most of the reported cases and usually mimic CBD calculus.7,9 Cipolletta et al.5 reported retrieval of a surgical gauze from CBD by endoscopic sphincterotomy. Cimsit et al.4 also reported a case of obstructive jaundice due to a textiloma mimicking a CBD calculus. In the presented report we found a surgical gauze causing obstruction in the biliary tract which was suggestive of a calculus or cholangiocarcinoma on initial evaluation. While the patients in the previous reports5,7 presented with either obstructive jaundice or cholangitis, the patient in our report had unusual absence of icterus despite the gauze being impacted in the hepatic duct and causing marked dilatation of IHBR on imaging studies. Another unusual feature was absence of symptoms suggestive of cholangitis and a late presentation, almost 10 years after the initial operation. The exact mechanism explaining migration of gauze into CBD is elusive however transperitoneal migration of foreign bodies into the bile duct have been described.1 Transmural migration of surgical mop into the intestine secondary to erosion9 has been described in literature and could explain the finding. Also some surgeons while performing open cholecyctectomy with choledochotomy in older days for calculus extraction used to pack the CBD proximally with gauze to prevent proximal migration may have been accidentally left behind. Late presentation and absence of jaundice could be explained by possible partial obstruction of CBD.

Endoscopic sphincterotomy can be diagnostic and is also advocated as procedure of choice for extraction of foreign bodies within the biliary tract.5 The procedure was not feasible in our case owing to failure to successfully cannulate the ampulla. Pre-operative evaluation may not appropriately identify the real cause of obstruction in patients with intrabiliary foreign bodies especially in the setting of unusual presentation as in our case. Further in patients who have been operated previously the possibility of a foreign body causing obstruction to biliary tract should be borne in mind.

Fig. 1.Magnetic resonance cholangiopancreatography of the patient showing dilatation of intra-hepatic biliary radicals and dilated hepatic ducts with a signal-void mass lesion of the common bile duct.
Fig. 2.Choledochotomy and retrieval of gauze from the common bile duct.
  1. Toland, CG. Foreign bodies in biliary tract. Ann Surg, 1933;98;904-908.
    Pubmed
  2. Kaji, H, Asano, N, Tamura, H, Yuh, I. Common bile duct stone caused by a fish bone: report of a case. Surg Today, 2004;34;268-271.
    Pubmed
  3. Szanto, I, Gamal, EM, Banai, J, Bajtai, A, Bozalyi, I, Dobo, I. Common bile duct stone formation induced by tomato skin following endoscopic sphincterotomy. Endoscopy, 1994;26;712.
    Pubmed
  4. Cimsit, B, Keskin, M, Ozden, I, Alper, A. Obstructive jaundice due to a textiloma mimicking a common bile duct stone. J Hepatobiliary Pancreat Surg, 2006;13;172-173.
    Pubmed
  5. Cipolletta, L, Bianco, MA, Rotondano, G, et al. Endoscopic retrieval of a surgical gauze from the common bile duct. Ital J Gastroenterol Hepatol, 1997;29;58-61.
    Pubmed
  6. Ahn, SI, Lee, KY, Kim, SJ, et al. Surgical clips found at the hepatic duct after laparoscopic cholecystectomy: a possible case of clip migration. Surg Laparosc Endosc Percutan Tech, 2005;15;279-282.
    Pubmed
  7. Ban, JL, Hirose, FM, Benfield, JR. Foreign bodies of the biliary tract: report of two patients and a review of the literature. Ann Surg, 1972;176;102-107.
    Pubmed
  8. Simmons, TC, Essilfie, W, Fleming, A. Obstructive jaundice occurring 40 months after gunshot wound to the left thoraco-abdomen. Gastrointest Endosc, 1998;48;423-425.
    Pubmed
  9. Sarkar, MM, Kibira, AK, Haque, MM, Sarkar, KP, Rahman, MK. Spontaneous transmural migration of a retained surgical mop into the small intestinal lumen causing sub-acute intestinal obstruction: a case report. TAJ, 2006;19;34-37.

Article

Case Report

Gut Liver 2011; 5(2): 245-247

Published online June 30, 2011 https://doi.org/10.5009/gnl.2011.5.2.245

Copyright © Gut and Liver.

Diagnostic Dilemma in an Unusual Case of Common Bile Duct Obstruction

Vimal Bhandari*, Mohit Singh, Hari Gopal Vyas, Nitin Sharma, and Rajkumar Chejara

Department of Surgery, Vardhaman Mahavir Medical College and Safdarjang Hospital, New Delhi, India.

Correspondence to: Vimal Bhandari. Department of Surgery, Vardhaman Mahavir Medical College and Safdarjang Hospital, D II/24 East Kidwai Nagar, New Delhi 110-023, India. Tel: +91-9899027348, Fax: +91-1126191877, mohitsingh24@gmail.com

Received: March 12, 2010; Accepted: May 19, 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Biliary obstructions are rarely caused by a foreign body and have received sparse attention. We present an unusual case with pruritis and abdominal pain caused by impacted full length surgical gauze within the common bile duct. The patient had previously undergone an open cholecystectomy. Radiological investigations were inconclusive and suggestive of either a calculus or a cholangiocarcinoma. Surgical exploration revealed full length surgical gauze within the common bile duct. Because imaging modalities are often non-determinant, the possibility of biliary tract obstruction from a foreign body should be borne in mind for patients with unusual presentations, especially those who have previously undergone surgery.

Keywords: Foreign body, Bile duct obstruction

INTRODUCTION

Obstructive jaundice is commonly caused by a stone or growth in common bile duct (CBD). Foreign bodies in the biliary tract like sutures,1 fish bone,2 tomato skin,3 surgical gauze,1,4,5 and chicken bone6 represent an uncommon clinical entity and are rare cause of biliary obstruction.1,4 However with recent advancements in endoscopic and laparoscopic surgery an increasing number of impacted foreign bodies like endoclips have been reported.1 The previous reported cases with impacted surgical gauze in CBD had classical presentation of obstructive jaundice.1,4,5 We report a unique case of 45-year-old female who presented with abdominal pain and itching caused by surgical gauze impacted in the biliary tree without any clinical evidence of jaundice and cholangitis.

CASE REPORT

A 45-year-old female presented to out patient clinic with complaints of severe itching and occasional attacks of abdominal pain for past 2 to 3 months. She had undergone open cholecystectomy 10 years back however no operative details of the procedure were available. Physical examination was unremarkable except for itch marks over the abdomen and operative healed scar with primary intention in the right subcostal region. No lump was palpable on per abdomen examination. Laboratory parameters demonstrated leukocyte count 8,700/cu.mm, serum alkaline phosphatase 806 IU/mL, total serum Bilirubin 1.4 mg/dL with conjugated fraction 1.0 mg/dL. Ultrasonography of the abdomen showed dilated intrahepatic biliary radicals (IHBR) and dilated common hepatic duct with an echogenic structure of 36×33 mm size in the proximal bile duct with post-acoustic shadow suggestive of a calculus. Magnetic resonance cholangiopancreatography (MRCP) also revealed marked dilatation of the IHBR and hepatic duct with signal void lesion in the distal CBD (Fig. 1). A heterogeneous mass was seen within CBD extending proximally towards the porta hepatis suggesting possibility of cholangiocarcinoma arising from the hepatic duct. Computed tomography was inconclusive and could not define the cause of obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted but cannulation failed. A differential diagnosis of calculus with secondary cholangiocarcinoma was made and exploratory laparotomy was planned. On surgical exploration no obvious growth or lymph nodes were seen. A soft to firm structure was palpable within the CBD and the hepatic ducts. Choledochotomy revealed full length surgical gauze lying within the proximal CBD and common hepatic duct extending into the right hepatic duct (Fig. 2). The gauze was removed and CBD was closed over a T-tube. Gross examination of the retrieved gauze revealed staining with bile and few concretions. Cholangiogram performed on 14th post operative day revealed free flow into the duodenum. Patient had an uneventful postoperative course and was discharged subsequently. She remained free of symptoms on follow up at 3 months.

DISCUSSION

Biliary obstruction due to foreign bodies are uncommon and have been rarely described.1-8 Ban et al.7 reviewed the literature and found 63 patients of foreign objects in the biliary tract. Majority of these cases presented with biliary colic and jaundice was present in 46% of the patients. Commonly encountered foreign bodies included residuals from previous operations, mostly a suture ligature acting as a nidus for stone formation. Others included missiles and ingested materials. Penetrating injuries (missiles) usually present with a long symptom free period.7,8 There is documented susceptibility to reflux of food into the biliary system and foreign bodies like fish bone and tomato skin2,3 have been retrieved in patients with enteric-biliary anastomosis or those who had endoscopic sphincterotomy. Recently with increase in laparoscopic cholecystectomy, foreign bodies like clips have also been reported within the biliary tract.6 Roentogenologic investigations are usually unrewarding. Plain X-rays of abdomen have revealed foreign bodies in only a few cases and correct diagnosis was not possible in majority.7 Ultrasonography and MRCP findings are also inconclusive in most of the reported cases and usually mimic CBD calculus.7,9 Cipolletta et al.5 reported retrieval of a surgical gauze from CBD by endoscopic sphincterotomy. Cimsit et al.4 also reported a case of obstructive jaundice due to a textiloma mimicking a CBD calculus. In the presented report we found a surgical gauze causing obstruction in the biliary tract which was suggestive of a calculus or cholangiocarcinoma on initial evaluation. While the patients in the previous reports5,7 presented with either obstructive jaundice or cholangitis, the patient in our report had unusual absence of icterus despite the gauze being impacted in the hepatic duct and causing marked dilatation of IHBR on imaging studies. Another unusual feature was absence of symptoms suggestive of cholangitis and a late presentation, almost 10 years after the initial operation. The exact mechanism explaining migration of gauze into CBD is elusive however transperitoneal migration of foreign bodies into the bile duct have been described.1 Transmural migration of surgical mop into the intestine secondary to erosion9 has been described in literature and could explain the finding. Also some surgeons while performing open cholecyctectomy with choledochotomy in older days for calculus extraction used to pack the CBD proximally with gauze to prevent proximal migration may have been accidentally left behind. Late presentation and absence of jaundice could be explained by possible partial obstruction of CBD.

Endoscopic sphincterotomy can be diagnostic and is also advocated as procedure of choice for extraction of foreign bodies within the biliary tract.5 The procedure was not feasible in our case owing to failure to successfully cannulate the ampulla. Pre-operative evaluation may not appropriately identify the real cause of obstruction in patients with intrabiliary foreign bodies especially in the setting of unusual presentation as in our case. Further in patients who have been operated previously the possibility of a foreign body causing obstruction to biliary tract should be borne in mind.

Fig 1.

Figure 1.Magnetic resonance cholangiopancreatography of the patient showing dilatation of intra-hepatic biliary radicals and dilated hepatic ducts with a signal-void mass lesion of the common bile duct.
Gut and Liver 2011; 5: 245-247https://doi.org/10.5009/gnl.2011.5.2.245

Fig 2.

Figure 2.Choledochotomy and retrieval of gauze from the common bile duct.
Gut and Liver 2011; 5: 245-247https://doi.org/10.5009/gnl.2011.5.2.245

References

  1. Toland, CG. Foreign bodies in biliary tract. Ann Surg, 1933;98;904-908.
    Pubmed
  2. Kaji, H, Asano, N, Tamura, H, Yuh, I. Common bile duct stone caused by a fish bone: report of a case. Surg Today, 2004;34;268-271.
    Pubmed
  3. Szanto, I, Gamal, EM, Banai, J, Bajtai, A, Bozalyi, I, Dobo, I. Common bile duct stone formation induced by tomato skin following endoscopic sphincterotomy. Endoscopy, 1994;26;712.
    Pubmed
  4. Cimsit, B, Keskin, M, Ozden, I, Alper, A. Obstructive jaundice due to a textiloma mimicking a common bile duct stone. J Hepatobiliary Pancreat Surg, 2006;13;172-173.
    Pubmed
  5. Cipolletta, L, Bianco, MA, Rotondano, G, et al. Endoscopic retrieval of a surgical gauze from the common bile duct. Ital J Gastroenterol Hepatol, 1997;29;58-61.
    Pubmed
  6. Ahn, SI, Lee, KY, Kim, SJ, et al. Surgical clips found at the hepatic duct after laparoscopic cholecystectomy: a possible case of clip migration. Surg Laparosc Endosc Percutan Tech, 2005;15;279-282.
    Pubmed
  7. Ban, JL, Hirose, FM, Benfield, JR. Foreign bodies of the biliary tract: report of two patients and a review of the literature. Ann Surg, 1972;176;102-107.
    Pubmed
  8. Simmons, TC, Essilfie, W, Fleming, A. Obstructive jaundice occurring 40 months after gunshot wound to the left thoraco-abdomen. Gastrointest Endosc, 1998;48;423-425.
    Pubmed
  9. Sarkar, MM, Kibira, AK, Haque, MM, Sarkar, KP, Rahman, MK. Spontaneous transmural migration of a retained surgical mop into the small intestinal lumen causing sub-acute intestinal obstruction: a case report. TAJ, 2006;19;34-37.
Gut and Liver

Vol.17 No.1
January, 2023

pISSN 1976-2283
eISSN 2005-1212

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