A Case of A 15-Year Old with Perforated Gallbladder Type II Secondary To Acute Acalculous Cholecystitis, Severe Secondary to Typhoid Fever with Bile Peritonitis, in Sepsis

Typhoid fever is one of the most common enteric fever in low to middle income countries. In the pediatric population, it is a rare cause of acalculous cholecystitis in which one of the dreaded complication is gall bladder perforation. This was a case of a 15-year-old male with 1-month history of intermittent undocumented fever, anorexia and weight loss. The patient presented with signs of pancytopenia and abdominal examination revealed acute abdomen. Patient was optimized and prepared for surgery. Intraoperative findings revealed Type II gall bladder perforation with bile peritonitis, and patient underwent exploratory laparotomy, cholecystectomy, lavage, Jackson-Pratt drain. The sepsis eventually resolved postoperatively, and the patient was discharged. Preoperative diagnosis in patients with gall bladder perforation is often challenging and sophisticated, due to its rarity. However, it should be considered as one of the differential diagnoses in pediatric patients presenting with atypical history of abdominal pain. At present, there are no specific guidelines in the management of complications such as gall bladder perforation in patients with typhoid fever. Therefore, early diagnosis and immediate surgical intervention of gall bladder perforation are of prime importance in the successful outcomes of these patients, given the high morbidity and mortality associated with this condition.

Bile Duct Injury in Children: Is There a Role for Early Endoscopic Retrograde Cholangiopancreatography?

Introduction Liver injury is common among pediatric abdominal trauma. Nonoperative management is the standard of care in isolated stable liver injuries. Bile leak is not an uncommon complication in moderate- and high-grade injuries. Case series Three pediatric patients (age: 10–15 years) suffered grade IV liver injuries secondary to blunt abdominal trauma. All developed significant bile leak treated nonoperatively with endoscopic retrograde cholangiopancreatography (ERCP), and patients 1 and 2 were treated with bile duct stent alone. Patient 3 required laparotomy for bile peritonitis and abdominal compartment syndrome followed by interval ERCP and bile duct stent. Conclusion Traumatic bile leaks if not recognized and managed early can result in significant morbidity. This paper describes the presentation and treatment of three pediatric patients with blunt liver trauma complicated by significant bile leaks that were managed successfully with ERCP and bile duct stent. This paper demonstrates the importance of early detection of bile leak to prevent bile peritonitis. Abdominal imaging 4 to 5 days postinjury can help in detecting bile accumulation. We believe that ERCP and bile duct stent are becoming the standard of care in diagnosing and treating traumatic bile leak. This paper confirms the safety and feasibility of this technique in the pediatric population.

Non-iatrogenic traumatic isolated bilothorax in a cat

Case summary A 6-month-old spayed female domestic shorthair cat presented for evaluation of suspected bite wounds over the right caudal thorax and left cranial flank. Thoracic radiographs identified a mild right-sided pneumothorax, a small volume of right-sided pleural effusion, with increased soft tissue opacity in the right cranial and middle lung lobes. Abdominal ultrasound identified a very small gall bladder and several small pockets of free peritoneal fluid. Cytological analysis of peritoneal fluid was consistent with a modified transudate. Following initial diagnostic investigations, yellow–orange fluid began to emanate from the right-sided thoracic wound. Biochemical analysis of this fluid was consistent with bile. Exploratory coeliotomy revealed a right-sided radial diaphragmatic tear, with herniation of the quadrate liver lobe and a portion of the gall bladder into the right pleural space. The gall bladder was bi-lobed and avulsion of a single herniated lobe resulted in leakage of bile into the right pleural cavity, without concurrent bile peritonitis (biloabdomen). The cat underwent total cholecystectomy and diaphragmatic defect repair and recovered uneventfully. Relevance and novel information To our knowledge, at the time of writing non-iatrogenic isolated bilothorax without concurrent biloabdomen has not been previously reported in the cat. This case highlights the importance of thorough assessment of cats with seemingly innocuous thoracic bite wounds. Despite the rarity of its occurrence, bilothorax should be considered a differential in cats with pleural effusion, even in the absence of bile peritonitis. We believe that the optimal treatment of cases of bilothorax is multifactorial and should be determined on a case-by-case basis.