Title : Bilious Ascites
 
Clinical Problem : A 6 months old girl presented with diarrhea and vomiting for 10 days and abdominal distension for 1 day. There was no edema elsewhere. There is history of clay stools. On examination, she was jaundiced and had ascites. Investigations showed:
• Hemoglobin = 9.3 gm, dl
• White cell count = 25,800 cells, cumm
• Platelets = 4,16,000 cells, cumm
• Bilirubin = 12 mg, dl {direct = 5.2 mg, dl}, SGOT = 56 IU, L, SGPT = 45 IU, L, total proteins = 3.2 gm, dl, albumin = 1.8 gm, dl and prothrombin time = 12.6 sec., PTT = 22.8 sec.
• Ascitic tap- bilious
• USG Abdomen – Hepatosplenomegaly with ascites.
 
Question : What is the cause of bilious ascites_?
 
Expert Opinion : This child had clay stools and direct jaundice with near normal liver enzymes suggestive of obstructive jaundice. Ultrasound abdomen has not shown any obstruction. However presence of bile in the peritoneum is suggestive of biliary leak. The commonest cause of biliary ascites is perforation in the common bile duct which could be due to trauma, infection or idiopathic. In this child, since there was diarrhea it is likely the infection predisposed to perforation. Perforation usually occurs in a weak wall and most likely cause of perforation should be choledochal cyst. On operation, it was found to be perforated choledochal cyst.
 
Funding : None
 
Conflict of Interest : None
 
DOI No. : 10.7199/ped.oncall.2014.6
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