|Year : 2015 | Volume
| Issue : 3 | Page : 249-250
Biliary peritonitis due to gall bladder perforation after percutaneous nephrolithotomy
Nikhil Ranjan, Rana Pratap Singh, Rajesh Tiwary
Department of Urology, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, India
|Date of Web Publication||1-Jul-2015|
Dr. Nikhil Ranjan
Department of Urology, Old Mdh q 3/5, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A 19-year-old male patient underwent right percutaneous nephrolithotomy (PNL) for right renal 1.5 × 1.5 cm lower pole stone. The procedure was completed uneventfully with complete stone clearance. The patient developed peritonitis and shock 48 h after the procedure. Exploratory laparotomy revealed a large amount of bile in the abdomen along with three small perforations in the gall bladder (GB) and one perforation in the caudate lobe of the liver. Retrograde cholecystectomy was performed but the patient did not recover and expired post-operatively. This case exemplifies the high mortality of GB perforation after PNL and the lack of early clinical signs.
Keywords: Biliary peritonitis, gall bladder perforation, percutaneous nephrolithotomy
|How to cite this article:|
Ranjan N, Singh RP, Tiwary R. Biliary peritonitis due to gall bladder perforation after percutaneous nephrolithotomy. Indian J Urol 2015;31:249-50
| Introduction|| |
Gall bladder (GB) perforation is a rare visceral complication of percutaneous nephrolithotomy (PNL) that carries a high mortality. We report a case of biliary peritonitis due to GB perforation that occurred after an otherwise uneventful PNL.
| Case Report|| |
A 19-year-old male patient underwent PNL for a 1.5 × 1.5 cm right renal lower pole stone. The patient was thin and underweight for his age. PNL was performed under fluoroscopic guidance in the prone position under general anesthesia. Stone-guided bull's eye puncture with fluoroscopy unit in 0 degree and 30 degree was performed with an 18 gauge needle. A single sub-costal puncture was performed via lower pole posterior calyx. After the C arm showed the needle near the desired calyx in 0 degree, it was rotated to 30 degree toward the surgeon and access to the calyx was sought by aligning the needle with it. This step required minor adjustments and resulted in multiple passes (about six) of the puncture needle. The tract was dilated with amplatz sequential dilators to 28 Fr. The stone was removed in toto without use of lithotripsy and a 26 Fr nephrostomy tube (PCN) was applied. The patient recovered well after the operation and was asymptomatic for the next 2 days except for mild abdominal pain. His urine output was good (2 L/24 h) and non-hemorrhagic. His nephrostomy output was clear and was left in situ for 2 days according to the institutional protocol. On the evening of the second post-operative day, the patient developed abdominal distension and pain along with hemodynamic instability (BP = 90/60), tachycardia and decreased urine output. X-ray abdomen did not reveal any free air in the abdomen or air fluid levels. X-ray chest was normal and ultrasound (USG) abdomen revealed free fluid in the abdomen. The patient deteriorated further and required ion tropic support. An antegrade pyelogram did not reveal any abnormality. An USG-guided pelvic drain was placed that extruded 1.5 L of golden yellow bilous aspirate. A general surgery consultation was sought and a decision for exploratory laparotomy was made. Exploratory laparotomy was performed on the third post-operative day, about 56 h after the procedure. Exploratory laparotomy revealed free bilous fluid in the abdomen. Three small perforations were noted in the body of the GB on the posterior surface. A small perforation was noted in the caudate lobe of the liver. Retrograde cholecystectomy was performed due to dense adhesions in the Calot's triangle. The whole gut was carefully examined along with mobilization of the right colon and Kocherisation More Details of the duodenum, but no other perforation was identified. The patient continued to deteriorate post-operatively. He required mechanical ventilation and expired 30 h after the laparotomy.
| Discussion|| |
Isolated GB perforation is a rare complication of PNL with few cases reported in the literature. The initial clinical signs include dyspepsia, nausea and abdominal pain. This subtle presentation leads to a delay in diagnosis. Cases carry a high mortality due to delay in diagnosis and the irritant nature of the bile. Saxby et al. described a case of GB perforation that was diagnosed 48 h after the procedure and treated with laparoscopic procedure and cholecystectomy.  Kontothanassis et al. described two cases where, in the first case, the patient underwent exploratory laparotomy for biliary peritonitis with cholecystectomy and insertion of a T-tube into the bile duct 48 h after standard PNL. The other patient had GB injury due to percutaneous nephrostomy performed for hydronephrosis. The patient underwent exploratory laparotomy and cholecystectomy 12 h after the procedure for biliary peritonitis. The authors report that the GB contained a microscopic injury.  Turner et al. have reported the only case in the literature where the diagnosis was made intraoperatively by opacification of the GB by a radiocontrast agent. They treated the patient with laparoscopic cholecystectomy.  Ricciardi et al. described the first case of duodenal injury with biliary peritonitis caused by choledochal necrosis and bile leakage following PCNL. This is also the only case reported in the literature with a fatal outcome, with the cause designated as septic shock with acute respiratory distress syndrome.
GB perforation should be kept in mind during right-sided PNL in lean and thin patients. The distance between calyces of the right kidney and the GB can be as little as 2 cm. A combination of fluoroscopy and ultrasound should be used for access. In our case, the patient was thin and the initial access was directly stone guided, which may have contributed to the injury. Although the skin was punctured at a single point and the needle was placed at the desired calyx, thereafter the 18 G needle required adjustments with the C arm in 30 degree before free flow of urine was aspirated from the puncture needle. This step required multiple passes (about six) back and forth of the needle. Looking at the size and number of the GB perforations, we assume that this is the step at which the injury occurred. Surgeons tend to be more adventurous with a thin needle rather than with the thick dilators. We believe that even microscopic injuries to the GB are significant, and this has also been reported in the literature.  Credence to our theory comes from observations from cholecystectomy, where sometimes a tense GB needs to be aspirated before removal. It is observed that the needle aspiration point continues to leak bile continuously. Absence of free air under the diaphragm also occurs in the absence of concomitant bowel injury.
Most cases in the literature have reported an average delay of 48 h to diagnosis, matching our own time period of 56 h.  All cases reported in the literature have required open or laparoscopic cholecystectomy. 
| Conclusion|| |
Urologists performing PNL must keep the possibility of biliary peritonitis in mind, especially when a thin patient develops unexplained peritonitis after a right-sided procedure. Laparotomy or laparoscopy is the most definite way to diagnose this condition as there is an absence of early clinical signs. It must be remembered that the condition is a life-threatening complication if there is delay or failure to diagnose.
| References|| |
Saxby MF. Biliary peritonitis following percutaneous nephrolithotomy. Br J Urol 1996;77:465-6.
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.
Fisher MB, Bianco Jr FJ, Carlin AM, Triest JA. Biliary peritonitis complicating percutaneous nephrolithotomy requiring laparoscopic cholecystectomy. J Urol 2004;171:791-2.
Kontothanassis D, Bissas A. Biliary peritonitis complicating percutaneous nephrostomy. Int Urol Nephrol 1997;29:529-31.
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