Biliary peritonitis: causes, symptoms, diagnosis, treatment

What diseases cause bile peritonitis?

After cholecystectomy, bile may leak from the bladder bed or from a leaky cystic duct. Increased pressure in the bile ducts, such as from an unremoved common bile duct stone, increases the flow of bile, and its accumulation around the bile ducts contributes to the development of a stricture.

After liver transplantation, bile leakage from the area of the bile duct anastomosis may occur.

Empyema or gangrene of the gallbladder may be complicated by its rupture with the formation of an abscess. The encapsulation of the spilled contents is facilitated by previously formed adhesions.

Traumatic causes of biliary peritonitis include blunt or gunshot wounds to the bile ducts and, rarely, puncture of the gallbladder or dilated intrahepatic duct during puncture biopsy of the liver, as well as during PTC in patients with severe cholestasis. Bile leakage is sometimes observed after surgical liver biopsy.

Spontaneous biliary peritonitis may develop in severe, prolonged mechanical jaundice without visible damage to the bile ducts. This phenomenon is explained by the rupture of small intrahepatic ducts.

Perforation of the common bile duct is very rare and is caused by the same reasons as perforation of the gallbladder: increased pressure in the bile ducts, erosion of the wall by a stone and its necrosis as a result of vascular thrombosis.

Sometimes jaundice in newborns is caused by spontaneous perforation of the extrahepatic bile ducts, which is most often localized at the confluence of the cystic and common hepatic ducts.

The pathogenesis of this process is unclear.

Symptoms of bile peritonitis

The severity of symptoms depends on the extent of bile spread throughout the abdominal cavity and its infection. Bile entering the free abdominal cavity leads to severe shock. Bile salts chemically irritate the peritoneum, causing exudation of large volumes of plasma into the ascitic fluid. The outpouring of bile is accompanied by severe diffuse abdominal pain. On examination, the patient is motionless, the skin is pale, low blood pressure, persistent tachycardia, board-like rigidity and diffuse tenderness on palpation of the abdomen are noted. Intestinal paresis often develops, so biliary peritonitis should always be excluded in patients with unexplained intestinal obstruction. A secondary infection occurs after a few hours, which is manifested by an increase in body temperature against the background of persistent abdominal pain and tenderness.

Laboratory findings are unremarkable. Hemoconcentration may be present; laparocentesis reveals bile, usually infected. Serum bilirubin levels increase, and alkaline phosphatase activity increases later. Cholescintigraphy or cholangiography reveals bile leakage. Endoscopic or percutaneous biliary drainage improves the prognosis.

Treatment of bile peritonitis

Replacement infusion therapy is mandatory; in case of paralytic intestinal obstruction, intestinal intubation may be required. Antibiotics are prescribed to prevent secondary infection.

If the gallbladder ruptures, cholecystectomy is indicated. If bile leaks from the common bile duct, endoscopic stenting (with or without papillosphincterotomy) or nasobiliary drainage can be performed. If bile leakage does not stop within 7-10 days, laparotomy may be required.