# Life-Threatening Biliary Peritonitis Following T-tube Removal: A Case Report and Literature Review

## TL;DR

A malnourished patient developed severe biliary peritonitis after T-tube removal, emphasizing the importance of risk assessment and timely intervention.

## Contribution

Highlights malnutrition as a modifiable risk factor for inadequate fistulous tract formation and biliary peritonitis.

## Key findings

- Incomplete fistulous tract formation led to acute biliary peritonitis after T-tube removal.
- Malnutrition was identified as a critical risk factor for poor tract formation and severe complications.
- Multidisciplinary care and timely surgical intervention improved patient outcomes.

## Abstract

Biliary peritonitis following T-tube removal represents a rare but potentially life-threatening complication of common bile duct exploration that underscores the critical importance of risk assessment and early intervention in T-tube management. This case report describes a 72-year-old severely malnourished male patient (body mass index (BMI) 18.1 kg/m²) with multiple comorbidities who underwent laparoscopic cholecystectomy with concomitant laparoscopic common bile duct exploration and T-tube placement for choledocholithiasis. Choledochoscopic findings at postoperative day 63 revealed incomplete fistulous tract formation at the time of T-tube removal, following which the patient developed acute and severe abdominal pain within 30 minutes, accompanied by elevated inflammatory markers. Despite aggressive conservative management, including broad-spectrum antibiotics and percutaneous drainage (800 mL of bile-stained fluid), the patient's clinical condition rapidly deteriorated to septic shock and respiratory failure within 48 hours. Emergency surgical intervention identified a 0.5×0.5 cm common bile duct fistula with extensive peritoneal bile accumulation, which was successfully repaired with new T-tube placement. Following intensive critical care management, the patient achieved complete recovery with hospital discharge after 41 days, and subsequent T-tube removal was uncomplicated. Twelve-month clinical follow-up demonstrated excellent functional outcomes with the restoration of normal appetite and absence of abdominal symptoms. This case emphasizes malnutrition as a critical and modifiable risk factor for inadequate fistulous tract formation and subsequent biliary peritonitis, highlighting the essential role of early clinical recognition, appropriate risk stratification, and coordinated multidisciplinary care with timely surgical intervention in optimizing patient outcomes.