Plastic-bag Suicide

Damage to the common bile-duct during operation for duodenal ulcer can be caused in several ways. First, difficulty in closing the duodenum distal to a penetrating posterior ulcer may be associated with excessive infolding of the duodenal stump, and resultant obstruction of the bile-duct, due either to direct pressure or to local inflammatory oedema. Secondly, the hasty underrunning, with a stitch, of a bleeding gastro-duodenal artery in relation to a posterior-wall duodenal ulcer may damage the common bile-duct, with subsequent risk of stenosis. Thirdly, the duct may be directly traumatized in its supraduodenal course during dissection of the upper border of the first part of the duodenum and ligation of the right gastric artery. Such a complication, if noticed at the time, requires immediate choledochostomy and insertion of a T tube, which is left in situ and removed at a later date. The first two complications described above are likely to pass unnoticed at operation, but usually give rise to signs of obstructive jaundice within a few days. Generally the jaundice resolves, and in these circumstances must be due to inflammatory and traumatic oedema. If, however, the jaundice deepens, ultimate cholecyst-jejunostomy will be necessary. Should the gall-bladder have been removed, or be the seat of chronic infection, then choledocho-jejunostomy is the treatment of choice. In the above case it would seem that infolding of the duodenal stump, associated with some infection, may have led to the fibrous stenosis of the ampulla of Vater. It is likely that the stricture had been present for almost two years before it finally caused obstructive jaundice, and it is unusual for this to occur at such a late stage. Lahey (1937) pointed out that a stricture of the common bile-duct may exist after operation on the biliary tract, but may cause insufficient narrowing of the lumen to retard flow of bile. Ultimate stenosis with the appearance of jaundice may nevertheless follow, due to the presence of continued or superimposed infection and the concurrent accumulation of mucus and biliary debris. A slowly progressing cholangitis may thus convert an insignificant stricture into almost complete obliteration of the common bile-duct. We assume that this was the explanation of the fatal obstructive jaundice in the case reported here, and it should be remembered that this complication can arise as a late as well as an early sequel to partial gastrectomy.