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A 45-year-old woman presented to the emergency department with nausea, vomiting, and abdominal pain. Her medical history was significant for mental retardation, morbid obesity, hypertension, chronic renal insufficiency requiring dialysis, insulin-dependent diabetes mellitus, congestive heart failure, and hydrocephalus controlled by a ventriculoperitoneal shunt. Liver function test results were normal. An uneventful open cholecystectomy was performed for porcelain gallbladder. On the 10th postoperative day, bilious drainage appeared in the incision. Liver function test results were normal except for a minimally elevated alkaline phosphatase level. Hepatobiliary iminodiacetic acid scan was performed (Figure 1), followed by an endoscopic retrograde cholangiopancreaticogram (Figure 2).
Image from hepatobiliary iminodiacetic acid scan at 30 minutes.
Endoscopic retrograde cholangiopancreaticogram.
A. Iatrogenic injury to the common bile duct
B. Cystic duct leak
C. Subvesical bile duct (Luschka) leak
D. Biliary shunt fistula
Bledsoe SE, Maull KI. Image of the Month—Quiz Case. Arch Surg. 2008;143(11):1127. doi:10.1001/archsurg.143.11.1127