A Rare Cause of Acute Cholangitis: Incarceration of the Biliopancreatic Limb Within an Incisional Hernia

Abstract

Cholangitis is a recognized complication following Roux-en-Y hepatojejunostomy, most commonly associated with anastomotic stricture or enteric reflux. Mechanical obstruction of the biliopancreatic limb is a rare cause that may impair biliary drainage and precipitate infection. We report the case of a 54-year-old patient with history of bile duct injury following cholecystectomy and Roux-en-Y hepatojejunostomy performed 25 years earlier, who presented with abdominal pain, fever, and jaundice. Physical examination revealed an incarcerated midline incisional hernia. Laboratory investigations demonstrated a cholestatic pattern with elevated inflammatory markers. Contrast-enhanced abdominal computed tomography showed herniation of the biliopancreatic limb through a midline abdominal wall defect, causing mechanical obstruction with proximal jejunal dilatation, an abrupt transition point at the hernia site, and associated upstream intrahepatic biliary dilatation. The patient underwent urgent surgical repair, with successful reduction of the herniated biliopancreatic limb, with no signs of bowel compromise, followed by abdominal wall repair with mesh reinforcement. Broad-spectrum antibiotic therapy was administered, and the postoperative course was uneventful, with complete clinical recovery. This case highlights a rare mechanical etiology of acute cholangitis in patients with altered biliary anatomy and underscores the importance of considering biliopancreatic limb obstruction in the differential diagnosis, as prompt recognition and surgical management are essential to prevent serious complications.