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PEARLS OF WISDOM |
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| Year : 2006 | Volume
: 22
| Issue : 1 | Page : 77-78 |
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Fulminant biliary peritonitis complicating percutaneous nephrostolithotomy
Mohammed CS Saheed, Sanjay H Bhat
Department of Urology, Amrita Institute of Medical Sciences, Kochi - 682026, India
Correspondence Address:
Sanjay H Bhat
Department of Urology, Amrita Institute of Medical Sciences, Kochi - 682026
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-1591.24666
How to cite this article:
Saheed MC, Bhat SH. Fulminant biliary peritonitis complicating percutaneous nephrostolithotomy. Indian J Urol 2006;22:77-8 |
 Introduction | |  |
Gall bladder injury is a rare visceral injury during percutaneous nephrostolithotomy (PNL). Unrecognised injuries can prove fatal when complicated by biliary peritonitis.
We would like to report a case of gall bladder injury during an uneventful PNL that developed fatal biliary peritonitis
| Case Summary | | |
46-year-old male with recurrent right renal calculi was referred to our center for surgery. He had undergone right Pyelolithotomy in the past for renal calculi. He also had a history of left Pyelolithotomy and left ureteric exploration to remove retained stent. He was evaluated and intravenous urogram showed three right renal calculi of 15 mm, 12 mm and 10 mm sizes in the upper, mid and lower calyces respectively. He was planned for percutaneous nephrolithotomy and clearence of the calculi. The superior calyx was very well dilated and we planned for the access through that calyx. The initial puncture was done under fluoroscopy and bile was seen gushing out on removing the needle stillette. We pushed in contrast through the needle and it was seen to opacify the gall bladder [Figure - 1]. The needle was withdrawn quickly and the second puncture made. We completed the procedure through the second access tract and attained near complete clearance of stones. In the immediate postoperative period he developed fever and as drainage through the nephrostomy was minimal it was removed. He progressively developed features of sepsis with high grade fever and hypotension that needed inotropic support by day 4. His abdomen remained soft and there was no icterus. Gastintestinal surgical consultation was taken and a CT scan with oral contrast was ordered. This revealed a few residual stone fragments but no evidence of peritonitis was seen. As his general condition deteriorated an abdominal paracentesis was done which revealed bile. Exploratory laparotomy revealed a litre of bile in the peritoneum leaking from a needle puncture in the gall bladder. A cholecystectomy was done [Figure - 2] and abdomen closed after copious lavage and placement of drains. He progressively deteriorated in spite of maximal inotropic support and broad-spectrum antibiotics and by day 14 had developed ischaemic enteritis (as revealed by multiple ileal perforations on relaparotomy). He expired on day 15.
| Discussion | | |
Gall bladder injuries constitute very small percentage of visceral injuries complicating percutaneous nephrostolithotomy and only four cases have been reported in English literature till date.[1],[2],[3] Patients with a recognized gall baldder injury occurring with percutaneous renal instrumentation require an immediate cholecystectomy.[3] The Biliary peritonitis resulting from injury can be fatal in upto 20% cases.[3] Delay in performing cholecystectomy can be fatal as revealed in this case.
The distended gallbladder is an immediate anterior relation to the right kidney. When the parenchyma is thin it is possible to puncture the gall bladder easily by over advancing the puncture needle. Although a gastrointestinal surgical consultation was obtained intraoperatively, it was felt that such minor punctures could be ignored. Our experience with this case shows that even in the absence of CBD obstruction, turning the patient over and first proceeding with a cholecystectomy and then completing the PCNL should treat such a minor puncture.
| References | | |
| 1. | Saxby MF. Biliary peritonitis following percutaneous nephrolithotomy. Br J Urol 1996;77:465-6.  [PUBMED] |
| 2. | Martin E, Lujan M, Paez A, Bustamante S, Berenguer A. Puncture of the gall bladder: An unusual cause of peritonitis complicating percutaneous nephrostomy. Br J Urol 1996;77:464-5. [PUBMED] |
| 3. | Fisher MB, Bianco Jr FJ, Carlin AM, Triest JA. Biliary peritonitis complicating percutaneous nephrolithotomy requiring laparoscopic cholecystectomy. J Urol 2004;171:791-2. |
[Figure - 1], [Figure - 2]
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