Exclusions: A perforation following trauma or surgery
Predisposing conditions:
(1) cholelithiasis and choledocholithiasis
(2) cholecystitis
(3) bile duct obstruction at the ampulla, typically by a tumor
(4) pregnancy (associated with decreased emptying of the gallbladder, increased gallbladder volume, and stone formation)
(5) diverticulum of the common bile duct
The predisposing conditions are usually associated with an obstruction at some point. This is followed by a combination of infection, venous thrombosis, mural necrosis and/or increased intraductal pressure which may be followed by rupture of the duct wall at the weakest point. The point of rupture is variable in the adult (as opposed to the point of rupture in the infant.
Clinical findings:
(1) onset may be insidious or acute
(2) abdominal pain
(3) fever
(4) jaundice
(5) abdominal distention
(6) bile in peritoneal fluid
(7) formation of a bile-rich loculated pseudocyts adjacent to the bile duct
(8) stools may be normal or clay-colored
Diagnosis can usually be made with an imaging study (intravenous cholangiography, technetium 99Tc HIDA scan, others). A cholangiogram will show extravasation of contrast medium.
