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Abstract: The patient, a 38-year-old female, had jaundice and fever symptoms continuously after laparoscopic cholecystectomy at a local hospital 2 months ago. After each anti-infection and hepatoprotective treatment, the condition was relieved, but recurrence and symptoms became increasingly severe, so she came to our hospital for consultation. After an abdominal CT examination, the patient was considered to have bile duct stenosis due to bile duct damage from the last surgery.
Basic information】Female, 38 years old
Disease Type】Bile Duct Injury, Bile Duct Stenosis
Hospital】Liaocheng People’s Hospital
Date of consultation】November 2021
Treatment plan】Surgical treatment (bile duct exploration + bile duct resection + biliary intestinal anastomosis) + medication (cefoperazone sodium for injection + glycopyrrolate diamine injection + ursodeoxycholic acid capsule + omeprazole enteric-coated tablets)
[Treatment period] 15 days of hospitalization, 1 month of postoperative review
【Treatment effect】 jaundice, fever symptoms disappeared, body restored to health
I. Initial interview
The patient visited the clinic in November 2021 and reported jaundice and fever for more than 1 month. He was treated with liver protection and anti-infection therapy at a local hospital, and his symptoms subsided, but he was prone to recurrence and progressive worsening. The patient’s medical history was followed up, and the patient had undergone laparoscopic cholecystectomy at the local hospital 2 months earlier for acute cholecystitis with heavy inflammation. According to the medical history, the first consideration is that it may be related to the last surgery, and it is possible that the inflammation of the last surgery has caused bile duct damage. The patient was admitted to the hospital because further treatment might require further improvement of abdominal CT and other examinations, and if it was clear that biliary stricture might require surgical exploration.
After hospitalization, the patient underwent liver function tests, which revealed significantly elevated transaminases and bilirubin and the presence of obstructive jaundice. On abdominal CT and abdominal MRI, the patient was found to have poorly displayed mid-bile ducts and mildly dilated intrahepatic bile ducts. In the present case, the condition was considered to be caused by bile duct injury leading to bile duct stenosis, but the possibility of biliary tract tumor was not excluded.
II. Treatment history
For the patient’s condition, surgical exploration was preferred, and then the surgical approach was decided based on the intraoperative exploration. After explaining the current situation to the patient, the patient expressed his agreement to the treatment plan. Subsequently, biliary exploration was given under general anesthesia. Intraoperatively, severe peribiliary adhesions were seen, and the middle segment of the bile duct was stenosed with the clips from the previous surgery visible around it. Therefore, inflammatory stenosis of the bile duct was considered and the cause was probably bile duct injury, and the patient was given a bile duct resection + bile-intestinal anastomosis. After the operation, the patient was given cefoperazone sodium for injection to anti-infection, glycopyrrolate diamine injection for liver protection, ursodeoxycholic acid capsule for biliary benefit, and omeprazole enteric soluble tablet for acid suppression.
III. Treatment effect
After the operation, the patient’s bilirubin and transaminase gradually decreased to normal, and the jaundice symptoms gradually disappeared. The patient recovered smoothly and started to eat on the third day after surgery, and the stitches were removed on the ninth day after surgery, and he was discharged from the hospital after 15 days of hospitalization. The patient’s jaundice and fever did not recur during the hospitalization, and the patient’s general condition improved significantly, and his eating and activities gradually returned to normal. Before discharge, the patient was instructed to repeat the examination after 1 month to clarify whether the liver function was recurrent and whether there was no fluid accumulation in the intra-abdominal surgical area or abdominal infection. If there is no other abnormality postoperative review can be done once every 1 year.
IV. Precautions
Patients are genuinely happy as doctors when their discomfort disappears after surgical treatment and drug therapy. Patients are advised to pay more attention to rest and get enough sleep after discharge from the hospital; pay attention to a light diet and increase nutrition, and can eat more high-protein and high-fiber foods such as eggs and tomatoes appropriately to promote recovery. In addition, patients need to pay attention to the fact that due to the surgery of biliary diversion, there is a possibility of fever and biliary tract infection caused by the return of intestinal fluid into the biliary tract, and if this happens, they should return to the hospital for review in time.
V. Personal insight
Biliary tract injury is often associated with laparoscopic cholecystectomy, which may be related to the difficulty of the operation and too much intraoperative inflammation. If patients have gallbladder stones and cholecystitis, they should be treated as early as possible so as not to delay the disease and cause the inflammation to worsen, making the surgery more difficult and leading to a higher chance of biliary tract injury. If bile duct injury leads to incomplete obstruction of the bile duct and symptoms continue to worsen with conservative treatment, it is possible that re-surgical treatment may be required. In cases of bile duct injury, as in this patient, a good outcome can usually be achieved with an aggressive treatment approach.