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CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 47-50

Common bile duct exploration in an infant with choledocholithiasis


Department of Pediatric Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, KSA

Date of Web Publication12-Apr-2017

Correspondence Address:
Abdullah Abdelfattah Elhosiny
Faculty of Medicine, King Abdulaziz University, Jeddah
KSA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_69_16

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  Abstract 

Management guideline for infantile cholelithiasis and choledocholithiasis is still controversial; various therapeutic strategies were reported successfully. This is a report of an 11-month-old male infant who presented with obstructive jaundice due to cholelithiasis. Prematurity, previous bowel surgery, and total parenteral nutrition were predisposing risk factors. The patient was successfully treated with cholecystectomy and open exploration of the common bile duct.

Keywords: Choledocholithiasis, cholelithiasis, infant


How to cite this article:
Elhosiny AA, ElHoussiny AA, Elkhouly MM, Rayes OM. Common bile duct exploration in an infant with choledocholithiasis. Saudi Surg J 2017;5:47-50

How to cite this URL:
Elhosiny AA, ElHoussiny AA, Elkhouly MM, Rayes OM. Common bile duct exploration in an infant with choledocholithiasis. Saudi Surg J [serial online] 2017 [cited 2020 Sep 29];5:47-50. Available from: http://www.saudisurgj.org/text.asp?2017/5/1/47/204421


  Introduction Top


Gallstones in infants under 1 year of age are uncommon. Furthermore, the majority of these infants stay asymptomatic and discovered on routine abdominal ultrasound, and eventually, most of them resolve spontaneously.[1],[2]

There are well-known risk factors for cholelithiasis in infants such as prematurity, previous bowel or cardiac surgeries, hemolytic disorders, infections, and total parenteral nutrition (TPN). However, some reported cases had no identifiable risk factor.[3],[4]

Symptomatic cholelithiasis and choledocholithiasis usually present with jaundice, clay-colored stool, irritability, and poor feeding. In addition, some cases develop complications such as cholecystitis and cholangitis.[2]

Various therapeutic strategies were reported in many cases;[1],[2],[3],[4],[5],[6],[7],[8],[9] herein, we describe a case of an 11-month-old male infant with choledocholithiasis that was successfully treated with laparoscopic cholecystectomy and a partially successful trial of laparoscopic exploration of the common bile duct (CBD) followed by open exploration.


  Case Report Top


An 11-month-old, preterm second twin male infant presented to the Emergency Department at King Abdulaziz University Hospital on September 21, 2015, with sudden progressive yellowish discoloration of the sclera and the face associated with clay-colored stool and dark urine for 4 days. In addition, he had a few vomiting episodes, and his abdomen was mildly distended. He was also irritable, cried a lot, and refused to eat. There was no family history of gallstones or hemolytic disorders.

He was delivered at 28-week gestation by cesarean section at private hospital in Jeddah. He was nursed in Neonatal Intensive Care Unit for 3 months during which he was put on TPN for 3 weeks. He also developed necrotizing enterocolitis that resulted in small bowel necrosis for which bowel resection and ileostomy were performed.

At the age of 2 months, his ileostomy complicated with stricture and underwent a second operation to relieve his intestinal obstruction.

On examination, the patient was vitally stable, febrile, active, alert, and well hydrated with jaundice. His abdomen was soft and lax, mildly distended with hepatomegaly about 4 cm below the costal margin, round edge, firm, not tender with a span of 8.5 cm, with no other significant findings on examinations.

Initial laboratory work showed elevated liver enzymes such as alkaline phosphatase (ALP): 871, gamma-glutamyl transferase: 435, aspartate aminotransferase: 146, alanine aminotransferase: 148, bilirubin-total (B-T): 57, with no leukocytosis [Table 1].
Table 1: Patient's laboratory tests

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Initial ultrasound showed one large stone in the gallbladder measuring 0.5 cm, [Figure 1] and [Figure 2] large stones in the CBD measuring 0.5 and 0.8 cm with dilatation of the CBD measuring 0.6 cm [Figure 2] and [Figure 3]. He was admitted to the pediatric intensive care unit and underwent operation on the next day.
Figure 1: The gallbladder demonstrates intraluminal stone measures 0.5 cm

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Figure 2: The common bile duct is dilated and measures 0.6 cm, and shows two large stones, 1st one measures 0.5 cm, and the 2nd one measures 0.8 cm

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Figure 3: The liver is mildly enlarged and measures 7.5 cm with normal parenchyma echo texture

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Operation details

A laparoscopic cholecystectomy was started, finding significant dilatation of the CBD and cystic duct and significant bowel adhesions related to the previous surgeries. After clipping the cystic artery and cystic duct, operative cholangiogram was performed through an incision at the cystic duct. We noted that the catheter (3 Fr) was not passing smoothly into the CBD although the diameters of both ducts were large. Operative cholangiogram showed the filling defects at the distal end of the dilated extrahepatic biliary passages. After failed trials retrieving the stones using Dormia basket, Fogarty catheter, and different graspers, we converted to open surgery.

Through right-sided subcostal incision, we reached the field and again through the large cystic duct tried repeatedly with different types of forceps, Fogarty catheter, and Dormia basket, but again both did not pass beyond the CBD distal obstruction. Hence, through CBD choledochotomy, the tiny passage toward the duodenum could only be calibrated with probe. We proceeded to duodenotomy to make sure of the patency of CBD till the ampulla of Vater. After all probing and maneuvering, debris of stones was the only obstructing agents found. The choledochotomy was closed; then, the duodenotomy closed transversely in two layers. Feeding tube size 8 Fr was left as a tube drain inside the CBD through the cystic duct stump and a silicon soft drain in the subhepatic area.

After the operation, antibiotics were continued with other postoperative care. Significant clinical improvement was noted 3 days after operation, in which the patient regained his activities and started tolerating oral feed. His laboratory results were near-normal by the 10th postoperative day, except for the ALP, which is expected in this condition [Table 1].

He was discharged well with a regular 1-week follow-up. Tubes were removed around 18 days after the operation, and an ultrasound studies were done before and after tubes removal, and they showed no stones and no duct dilatation [Figure 4] and [Figure 5].
Figure 4: No gallbladder dilatation, stones, or any collection can be seen

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Figure 5: No common bile duct dilatation, stones, or any collection can be seen

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  Discussion Top


At present, the incidence of reported cholelithiasis and choledocholithiasis in infants is increasing, but the management guidelines are still controversial because of the lack of systemic studies. In addition, different therapeutic strategies were reported successfully in many cases.

Starting with conservative management, spontaneous resolution was reported successfully in most of the asymptomatic cases.[1],[5] Symptomatic patients, on the other hand, usually required medical or surgical intervention. In addition, a retrospective study suggested that only those patients with reversible risk factors can have a spontaneous resolution, and those with irreversible risk factors such as previous bowel surgeries usually require intervention.[2] A medical management using ursodeoxycholic and antibiotic with no surgical intervention was also reported successfully [3],[6]

With regard to surgical intervention, physicians tend to go for less invasive procedures due to the risk of morbidities in this group of age. However, our patient was treated successfully with cholecystectomy and open CBD exploration with no complications. A laparoscopic CBD exploration was also reported successfully by other authors.[7] Other less invasive strategies that were suggested by other physicians include radiological washing of stones using percutaneous tube,[8] balloon sphincteroplasty,[9] and endoscopic retrograde cholangiopancreatography.[4] Moreover, all of these reports showed similar success rate to our case.


  Conclusion Top


Infants can present with obstructive jaundice due to gallstones, as for medical and minimally invasive procedures, this condition can be treated successfully with cholecystectomy and open CBD exploration with similar success rate and low rate of morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Keller MS, Markle BM, Laffey PA, Chawla HS, Jacir N, Frank JL. Spontaneous resolution of cholelithiasis in infants. Radiology 1985;157:345-8.  Back to cited text no. 1
    
2.
Jeanty C, Derderian SC, Courtier J, Hirose S. Clinical management of infantile cholelithiasis. J Pediatr Surg 2015;50:1289-92.  Back to cited text no. 2
    
3.
Nordin N, Alex G, Clarnette T, Stephens N, Oliver M. Common bile duct stones in infancy: A medical approach. J Paediatr Child Health 2012;48:705-9.  Back to cited text no. 3
    
4.
Thomas M, Kadiwar K, Domajnko B, Santos MC. Choledocholithiasis in a 4-month-old infant. J Pediatr Surg 2007;42:E19-21.  Back to cited text no. 4
    
5.
St-Vil D, Yazbeck S, Luks FI, Hancock BJ, Filiatrault D, Youssef S. Cholelithiasis in newborns and infants. J Pediatr Surg 1992;27:1305-7.  Back to cited text no. 5
    
6.
Maruyama K, Koizumi T. Choledocholithiasis in an infant of extremely low birthweight. J Paediatr Child Health 2002;38:204-5.  Back to cited text no. 6
    
7.
Wilcox DT, Casson D, Bowen J, Thomas A, Bruce J. Cholelithiasis in early infancy. Pediatr Surg Int 1997;12:198-9.  Back to cited text no. 7
    
8.
Puri P. Radiological treatment of common bile duct lithiasis in infancy. J Pediatr Surg 1989;24:946.  Back to cited text no. 8
    
9.
Kalfa D, Barthet M, Chaumoître K, Panuel M, Sabiani F, Alessandrini P, et al. Balloon sphincteroplasty in the management of choledocholithiasis in a 10-week-old infant. Surg Laparosc Endosc Percutan Tech 2008;18:89-91.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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