Membraneous By A. Pint&,
Obstruction I. Pilaszanovich, P&s,
of the Common Bile Duct J. Schtifer,
and
J. Weisenbach
Hungary
In 1967at the age of 32 days, G.P. presented with jaundice present since the 10th day of life. On admission, his liver was found to extend 1 cm below the costal margin. Stools were white, the urine was dark, and the bile was strongly positive. Total serum bilirubin was II .8 mg/lOO ml. direct 8.7 mg/lOO ml. At laparotomy a few days later, the liver was mildly enlarged and of slightly greenish color. The hepatic ducts and the common bile duct were about 1 cm in diameter, and the cystic duct was thin. The gallbladder was almost empty. The common bile duct extended downward behind the duodenum, maintaining its diameter throughout its course. One of the hepatic ducts was drained, and 6 ml of dark green bile was withdrawn. A cholangiogram was then made, which showed the intrahepatic bile ducts, the tortuous ducts, the fine cystic duct, and the common bile duct ending blindly behind the duodenum. There was no passage into the duodenum (Fig. I). The gallbladder was not visualized. The duodenum was also opened without finding an entrance to the common bile duct. A rubber probe was inserted into the opening of the common bile duct and passed downward. Through the opening in the duodenum it became apparent that a membrane located at the level of the ampulla of Vater prevented the probe from getting into the small intestine. The membrane was about 0.5 mm thick and there was no hole in it. On account of the thinness of the membrane, the probe was faintly visible through it. Instead of transecting the common bile duct and turning it forward for a choledochoduodenostomy, the membrane was incised and stretched. Then, a thin catheter with a few holes in its wall was introduced into the opening of the common bile duct and was passed through the dissected membrane into the duodenum. The other end of the catheter was brought out through the abdominal wall. During the first 3 postoperative days the bile was discharged via the catheter, and later it was passed with the normal enteral circulation. By the 10th day the jaundice had disappeared and the stools became green and later yellow in color. By 10 days total serum bilirubin was 1.5 mg/lOO ml, direct I.0 mg/lOO ml.
Fig. 1. lntraoperative cholangiogram.
0 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 10, No. 5 (October), 1975
839
840
CASE REPORTS
FOLLOW-UP At the age of 18 mo the child had not had jaundice or attacks of cholangitis since surgery. A liver needle biopsy showed normal tissue. At 7 yr he is an extremely well-built, large, vigorous and mentally normal boy without any pathologic signs. Infusion cholecystography showed a normal common bile duct and a pear-shaped gallbladder of normal size. Duodenography showed no reflux from the duodenum into the common bile duct, and liver needle biopsy revealed normal tissues. DISCUSSION The literature available to us contains no similar case. Personal communications reveal a single case of membraneous atresia of the common bile duct.
also failed to
Obstruction I. Pilaszanovich, P&s,
of the Common Bile Duct J. Schtifer,
and
J. Weisenbach
Hungary
In 1967at the age of 32 days, G.P. presented with jaundice present since the 10th day of life. On admission, his liver was found to extend 1 cm below the costal margin. Stools were white, the urine was dark, and the bile was strongly positive. Total serum bilirubin was II .8 mg/lOO ml. direct 8.7 mg/lOO ml. At laparotomy a few days later, the liver was mildly enlarged and of slightly greenish color. The hepatic ducts and the common bile duct were about 1 cm in diameter, and the cystic duct was thin. The gallbladder was almost empty. The common bile duct extended downward behind the duodenum, maintaining its diameter throughout its course. One of the hepatic ducts was drained, and 6 ml of dark green bile was withdrawn. A cholangiogram was then made, which showed the intrahepatic bile ducts, the tortuous ducts, the fine cystic duct, and the common bile duct ending blindly behind the duodenum. There was no passage into the duodenum (Fig. I). The gallbladder was not visualized. The duodenum was also opened without finding an entrance to the common bile duct. A rubber probe was inserted into the opening of the common bile duct and passed downward. Through the opening in the duodenum it became apparent that a membrane located at the level of the ampulla of Vater prevented the probe from getting into the small intestine. The membrane was about 0.5 mm thick and there was no hole in it. On account of the thinness of the membrane, the probe was faintly visible through it. Instead of transecting the common bile duct and turning it forward for a choledochoduodenostomy, the membrane was incised and stretched. Then, a thin catheter with a few holes in its wall was introduced into the opening of the common bile duct and was passed through the dissected membrane into the duodenum. The other end of the catheter was brought out through the abdominal wall. During the first 3 postoperative days the bile was discharged via the catheter, and later it was passed with the normal enteral circulation. By the 10th day the jaundice had disappeared and the stools became green and later yellow in color. By 10 days total serum bilirubin was 1.5 mg/lOO ml, direct I.0 mg/lOO ml.
Fig. 1. lntraoperative cholangiogram.
0 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 10, No. 5 (October), 1975
839
840
CASE REPORTS
FOLLOW-UP At the age of 18 mo the child had not had jaundice or attacks of cholangitis since surgery. A liver needle biopsy showed normal tissue. At 7 yr he is an extremely well-built, large, vigorous and mentally normal boy without any pathologic signs. Infusion cholecystography showed a normal common bile duct and a pear-shaped gallbladder of normal size. Duodenography showed no reflux from the duodenum into the common bile duct, and liver needle biopsy revealed normal tissues. DISCUSSION The literature available to us contains no similar case. Personal communications reveal a single case of membraneous atresia of the common bile duct.
also failed to
