Biliary obstruction secondary to combat-related foreign bodies: report of two cases A. Kamona, A. Mansour, M. Qandeel, M. Al-Eshaiker Department of Radiology, King Hussein Cancer Center, Queen Rania Al Abdullah Street, P.O. Box 1269 AL-Jubeiha, Amman 11941, Jordan Abstract We present two cases with combat-related hepatic injury. These patients presented later with obstructive jaundice as seen on the percutaneous transhepatic cholangio- graphy. Combat-related injuries are a rare cause of ob- structive jaundice. Key words: Obstructive jaundice—PTC—Combat in- quiries Foreign bodies of the biliary tree represent infrequent causes of obstructive jaundice. We report two patients, one with a bullet in the common bile duct and the other with shrapnel in the common hepatic duct. They pre- sented 4 months and 13 years, respectively, after the initial injury. The symptom-free interval was initially due to the peripheral positions of the foreign bodies in liver tissue with gradual migration into the biliary tree. Case reports Case 1 A 14-year-old boy presented to the emergency depart- ment because of a bullet injury due to an unknown source and from an apparently long distance. Physical examination showed a 3-cm wound in the anterior aspect of the right hypochondrial region, which represented bullet entry without an exit wound. Plain films showed a bullet in the same region. An urgent ultrasound (US) scan showed the bullet within the liver parenchyma. The biliary tree was not dilated and neither abdominal fluid collection nor any other abnormality was detected. The patient was clinically stable with normal vital signs. The patient was kept under hospital observation for 2 days and then discharged without any surgical or other intervention. Four moths later the patient was readmitted to the hospitalforfever,nausea,vomiting,andabdominalpain. The patientÕs physical examination was significant for icteric sclera and tenderness to deep palpation of the right upper quadrant. He was febrile. Other vital signs were normal. The liver test showed a high total bilirubin level of 7.4 mg/dL and a direct bilirubin level of 7.1 mg/ dL. US examination showed a hyperechoic lesion that casted a shadow within the common bile duct and moderate biliary tree dilatation. Because of the history of bullet injury, magnetic resonance imaging was not per- formed and Percutaneous Transhepatic Cholangio- graphy (PTC) showed a dilated biliary tree with communicating cavities in both liver lobes that repre- sented suppurative cholangitis and a bullet in the com- mon bile duct (Fig. 1). The patient underwent common bile duct explora- tion, the bullet was recovered, and the patient received broad-spectrum antibiotics. The postoperative course was unremarkable. Case 2 A 44-year-old man who survived shrapnel wounds was hospitalized. The patient underwent emergency laparot- omy, and a partial small bowel resection was performed; no other abnormality was identified. The patientÕs post- operative course was unremarkable. Subsequent investi- gations by plain film and US confirmed the presence of shrapnel within the liver parenchyma, with normal bili- ary tree and hepatic vasculature. Thirteen years later, the patient was admitted to the hospital for nausea, vomiting, icterus, and abdominal pain. The physical examinant was significant for icteric sclera. The patient was febrile with normal vital signs. His total bilirubin level was high at 8.1 mg/dL and the Correspondence to: A. Kamona; email: akamona@khcc.jo ª Springer Science+Business Media, Inc. 2005 Published online: 26 October 2005 Abdominal Imaging Abdom Imaging (2005) 30:748–749 DOI: 10.1007/s00261-005-0325-5