上段図１〜図９で総胆管（CBD）が1cm以上に拡張し，図９で嵌頓した結石を認める（↑）．

図１１〜図１４は省略．総胆管（CBD）拡張と結石嵌頓（図２５：↑）は前日と同所見である．何が変わったかと言えば図２４〜図３０で右側腎臓周囲から前腎傍腔に脂肪組織の浮腫（不均一で境界不鮮明な濃度上昇）または液貯留（均一で境界鮮明な部分）を認める（▲）ことである．膵臓に腫大や，造影効果の低下を認めず急性膵炎は否定できる．図１７でIVCは正常な大きさだから脱水による血圧低下ではなく，臨床症状は急性閉塞性化膿性胆管炎によるものと思われるが，総胆管周囲に限局せず広範囲に浮腫と液貯留を示しているのは胆管炎だけでは説明がつかない．手術で総胆管の外背側に結石嵌頓部で穿孔を認めた．結石を摘除したら膿性胆汁が大量に流出した．穿孔部にT-チューブを挿入し，術後は順調に経過した．

文献考察：総胆管穿孔
１）Arch Surg. 2004 Oct;139(10):1083-7.
Nontraumatic perforation of the bile duct in adults.
Kang SB, Han HS, Min SK, Lee HK.
HYPOTHESIS: Nontraumatic perforation of the bile duct in adults is rare, and the management of this condition should resolve the primary pathologic lesion. DESIGN: Retrospective analysis of 11 patients who were diagnosed as having nontraumatic perforation of the bile duct. SETTING: A public university medical center and a private university medical center. PATIENTS: Five men and 6 women (median age, 64 years) with nontraumatic perforation of the bile duct were treated between September 1993 and May 2003. INTERVENTIONS: Two patients with common bile duct (CBD) stones, who were initially diagnosed as having mediastinal abscess and subcapsular biloma, respectively, were treated by nonoperative management, ie, endoscopic sphincterotomy and percutaneous abscess drainage. The remaining 9 patients were treated surgically, which included an exploration of the CBD, placement of a T tube, and a liver resection. MAIN OUTCOME MEASURES: Initial manifestation, primary disease, perforation site, management, surgical morbidity, and mortality. RESULTS: All patients had acute abdominal pain, which was caused by intraabdominal abscess in 7 patients, diffuse bile peritonitis in 3, and subcapsular biloma in 1. Their primary diseases were CBD stones in 7 patients, intrahepatic duct stone in 2, a choledochal cyst in 1, and phytobezoar with food stuff in the CBD in 1. Perforations occurred at the left intrahepatic duct in 9 patients, the CBD in 1, and the cyst wall in 1. All patients recovered, except 1 patient who expired owing to multiorgan failure because the operation could not be performed in time. CONCLUSIONS: Nontraumatic perforation of the bile duct should be suspected if perihepatic abscess or peritonitis is combined with biliary stone disease. The management of nontraumatic perforation of the bile duct should include the eradication of the primary pathologic lesion and the control of abscess or peritonitis.PMID: 15492148

２）成人にみられた総胆管穿孔の1例
　 Author：田辺義明(東京慈恵会医科大学 外科), 畝村泰樹, 大平寛典, 三澤健之, 小林進, 山崎洋次
　 Source：日本臨床外科学会雑誌(1345-2843)59巻8号 Page2123-2126(1998.08)
要旨：胆道穿孔症の本邦集計52例中，総胆管穿孔は32例（60％）で，他部位は総肝管，左肝管があげられている．総胆管穿孔例32例中結石を伴う例は20例で，胆嚢結石のみ6例，結石を伴わないものが6例であった．急性腹症で発症し緊急手術が行われる症例が多く，転帰は一般に良好である．