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At laparotomy, dark blood-stained fluid was demonstrated. The duodenum was regular, and necrosis of the common bile duct and gallbladder was observed. Intraoperative endoscopy confirmed no ulcers of the periampullar area. No signs of acute pancreatitis were found. The gallbladder was partially necrosed at the infundibulum, and a clear line of demarcation was present. A cholecystectomy was performed, and exploration of the whole extrahepatic biliary system revealed that it was completely gangrenous and sloughed up to inside the liver (Figure 2). We opted for a diagnosis of gallbladder and extrahepatic biliary system necrosis of undetermined origin and decided to place a T-tube drain inside the biliary system. The patient's clinical condition was compromised, with a clear septic state, and she died 5 hours after the operation in the intensive care unit.

Although gallbladder necrosis is a well-known complication of acute cholecystitis, extrahepatic biliary system necrosis is rare. Few cases are reported in MEDLINE, and they are usually associated with acute pancreatitis. The first case report¹ of necrosis of the choledochus caused by necrotizing acute pancreatitis was published in 1972. Later, a second case report² of necrosis of the common bile duct and almost all the common hepatic duct as a complication of acute pancreatitis in an 8-year-old boy was published in 2000; the patient was managed successfully with a Roux-en-Y hepaticojejunostomy. The possible mechanism of disease in such cases can be enzymatic digestion or ischemic damage to the extrahepatic biliary system, which in their extreme form can lead to necrosis and sloughing of the bile duct tree.

A case report³ of severe necrosis of the choledochus and associated duodenal perforation 1 week after percutaneous nephrolithotomy for kidney stones has also been published. External biliary derivation, duodenal exclusion, and gastrojejunal anastomosis is the preferred treatment.

Posttraumatic necrosis of the common bile duct as a consequence of blunt injury has also been described in a patient.⁴ In addition, a case report⁵ of necrosis of the entire extrahepatic biliary tract after cardiac catheterization was published, in which the authors hypothesized that the axial blood supply to these structures makes them susceptible to ischemic injury.

In the case reported herein, the mechanism that led to gangrene of the bile duct is not fully understood: the patient did not have acute pancreatitis, undergo any invasive procedure, or experience a traumatic event. The disorder could be caused by an exaggerated response to cholecystitis, but the extent of ischemic necrosis, limited to the proximal third of the gallbladder, was minimal compared with the massive gangrene of the bile duct. We hypothesize that diabetes mellitus may have had a role and possibly contributed to ischemic damage that caused necrosis. The rapid and dramatic evolution of the patient's clinical condition that led to her death a few hours after surgery was not surprising because of the severity of necrosis observed on the computed tomographic images, as well as the intraoperative findings.

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