Biliary Perforation in a Neonate – A Rare Cause of Infantile Cholestasis

Sir, Spontaneous biliary perforation is a rare disease in neonates. Infants present with abdominal distention with features of cholestasis.[1] Here, we describe a 4-week-old newborn presenting with cholestatic jaundice and spontaneous biliary perforation, admitted to the neonatal intensive care unit. A 4-week-old male baby presented with abdominal distention, jaundice, and passage of acholic stools. On examination, the baby had a distended abdomen with an umbilical hernia. Laboratory parameters showed leukocytosis, total bilirubin 9.8 mg/dl, direct bilirubin 5.1 mg/dl, aspartate transaminase 230 IU/L, alanine transaminase 161 IU/L, and alkaline phosphatase 360 IU/L. Paracentesis showed a greenish-colored aspirate diagnostic of biliary perforation. A hepatobiliary iminodiacetic acid (HIDA) scan was suggestive of the biliary leak in the proximal part of the common bile duct (CBD) [Figure 1]. The baby was kept nil per oral and started on total parenteral nutrition. Magnetic resonance cholangiopancreatography confirmed the presence of proximal CBD rupture with fluid collection in the subhepatic region and ruled out distal CBD obstruction [Figure 1]. Ultrasonography-guided pigtail insertion was done. Fluid output was monitored and gradually decreased by 2 weeks. A HIDA scan done on day 45 showed closure of the leak with intact biliary enteric drainage.Figure 1: (a) Hepatobiliary iminodiacetic acid scan showing hepatic uptake, excretion of radiotracer into the gallbladder, leakage in subhepatic pouch (arrow), and no tracer in bowel suggestive of common bile duct (CBD) perforation, (b) Magnetic resonance cholangiopancreatography shows proximal CBD perforation with mild sub-hepatic and right iliac fossa collection (arrow)CBD perforation is the second most common cause of surgical jaundice in infants after biliary atresia. It is commonly seen in the first 6 months of life. Presentation in the neonatal period is very infrequent.[2,3] Various causes postulated are congenital weakness of the duct, pancreaticobiliary malformations (PBM), and viral infection. Most cases are idiopathic, though secondary causes like PBM should be excluded. Treatment varies from nonoperative management with antibiotics, and percutaneous drainage to complex biliary-intestinal reconstruction in refractory cases.[1] CBD perforation should be considered in cases with cholestasis with abdominal distention. Most cases respond with conservative management. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.