Spontaneous “perforation” of the liver

62 y. o. f. patient admitted for obstructing jaundice. 2 days after ERCP, the day before planned surgery sudden bout of intense pain relieved by common analgesics. No decline in general status, but slight increase of jaundice and somewhat distended abdomen.

Treatment

Intraop dilated bowel loops, choleperitoneum 500 ml clear bile, source unknown. no apparent lesion of the bile ducts apart from the cholecystocholedochal fistula and choledocholithiasis (previously known), scirrous sigmoid carcinoma (incidental finding).

Cholecystectomy, duct clearance, T-tube. On completion cholangiograpy normal aspect of the named branches but contrast material appears to pool under the left liver.

Inspection of the left lobe after division of lig. teres and broadening incison showed in seg. III a gray area 3/4 cm wide , where liver parenchyma was laid bare by capsule necrosis. blind X stitches failed to close the leakage. Methilene blue injection using an “operative microscope” (the kind of device plastic surgeons use) showed 3 tiny duct openings in the mentioned area, and 2 more on the anterior liver margin.

Segmentectomy III, transverse loop colostomy.

There was no “purulent” cholangitis , i mean pus in the bile ducts, nor macroscopic appearance of liver metastasis. My boss thinks of a subcapsular bile collection that burst open but has no explanation for the phenomena.

Have you seen or read of similar conditions? Please send your learned comments, and please add some references if you have any, my quick Medline search did not yeld any results.

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