Spontaneous biliary peritonitis, or delayed bile leak?

INTRODUCTION: Spontaneous biliary peritonitis is a rare cause of acute abdominal pain. Whilst usually of extrahepatic origin, here we describe an even rarer perforation of an intrahepatic duct. PRESENTATION OF CASE: A 31 year old woman presented with acute onset epigastric abdominal pain on a background of cholecystectomy four years prior. Laparoscopy demonstrated bilious fluid but failed to identify the site of bile leak. Subsequent ERCP localised the leak to an anomalous radical of the right hepatic duct. DISCUSSION: Spontaneous biliary peritonitis is a rare diagnosis. Most cases are extrahepatic and the pathogenesis of intrahepatic ductal rupture has been difficult to define. Whilst acute bile leak is a recognised complication of cholecystectomy, bile leak four years following operation has not been described previously.
CONCLUSION: Spontaneous biliary peritonitis remains as a rare cause of acute abdominal pain. Within the context of cholecystectomy, the surgeon should always be alert to the possibility of delayed bile leak.