Postoperative Bile Duct Fistula and Liver Abscess from Laparoscopic Cholecystectomy Treated with Classical Homeopathy: A Case Report

Abstract

Introduction:

Bile duct fistulas (BDFs) stemming mainly from surgery after cholecystectomy present a significant global health challenge due to their associated morbidity and complications. If proven effective, alternative treatments may be preferred, given the invasive nature of the conventional treatment.

Case presentation:

This is the case of a 54-year-old female patient with bile duct injury that occurred during laparoscopic cholecystectomy, resulting in a BDF and liver abscess. Conventional treatment provided little benefit, resulting in a shift toward homeopathic treatment. Notably, homeopathy not only addressed immediate postoperative concerns but also played a beneficial role in healing the fistula and managing chronic conditions.

Conclusion:

The case showed sustained improvement in liver function and overall well-being throughout a 6-year follow-up, despite the initial grim prognosis. Further, research is imperative to gain a better understanding of the benefits of the treatment observed here.

Introduction

Bile duct fistula (BDF) is a rare condition where an abnormal connection forms between the bile ducts and the surrounding structures, leading to bile leakage. ¹ The incidence is estimated to be 0.3–0.7%. ¹ BDF may be primary, arising from biliary lithiasis, or secondary, resulting from an iatrogenic injury during gall bladder removal.^1,2 Postoperative bile duct injuries are classified using the Bismuth classification, ranging from type I to type V, representing different levels of anatomical involvement.^2,3 BDFs can cause symptoms such as abdominal pain, jaundice, and fever. Complications include the risk of infection, peritonitis, and ongoing bile leakage, which can contribute to nutritional deficiencies and malabsorption. ² BDF diagnosis involves imaging studies and clinical evaluation using techniques such as cholescintigraphy, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography to visualize the biliary system and identify the fistula site. ² Conventional treatment approaches for BDF often involve surgical intervention to repair the damaged duct and close the fistulous connection.^1,2 This case report suggests an alternative to explore for the treatment of BDF in postcholecystectomy through classical homeopathy. The authors are unaware of any prior case reports involving BDF and homeopathy.

Case Report

History of presenting complaints

On October 20, 2015, a 54-year-old female presented to the clinic with a BDF following a laparoscopic cholecystectomy performed on June 5th, 2015, in Moscow. The procedure caused a bile duct injury that went undiagnosed for 3 days, resulting in bile peritonitis and liver abscess. Classified as a Bismuth Type IV–V injury, it involved the destruction of the confluence and trauma to the right lobar duct.

She had undergone four prior surgeries at another facility to manage peritonitis and drain bile, but extensive tissue damage and liver abscess made immediate bile duct reconstruction unfeasible. On admission, she exhibited severe malnutrition (Body Mass Index 15.62 kg/m²), generalized weakness, icteric skin, and external biliary fistulas, with bile discharge ranging from 800 mL to 1 L daily.

Reconstructive surgery involved left hepatic enteroanastomosis via a Roux-en-Y loop and marginal liver resection. Despite the procedure, bile discharge persisted, reducing to 200–300 mL/day. Upon discharge, she developed pain at the surgical site and postcatheterization cystitis. At this juncture, the patient sought homeopathic help. The first consultation took place on October 22nd, 2015. The symptoms available for homeopathic prescription (as taken for homeopathic repertorization) were as follows:

• 1.

GENERALITIES—INJURIES (including blows, falls, and bruises)—operation, after (postoperative) (+++)

2.

BLADDER—INFLAMMATION (Cystitis)—injuries, after (++)

3.

BLADDER—URGING to urinate (morbid desire)—constant (++)

4.

BLADDER—URGING to urinate (morbid desire)—frequent (++)

5.

BLADDER—URINATION—frequent (++)

6.

BLADDER—PAIN—burning—neck (+)

7.

ABDOMEN—GALLBLADDER STONES (+)

8.

GENERALITIES—FISTULAE (+)

9.

GENERALITIES—FOOD AND DRINKS—salt desire (+++)

10.

GENERALITIES—FOOD AND DRINKS—sweets—aversion (+)

11.

SLEEP—POSITION—back, on (++)

12.

GENERALITIES—WARM—agg (++)

13.

GENERALITIES—SUN—from exposure to—agg (++)

Investigations

Ultrasonography performed before surgery on October 14, 2015, revealed that the liver was enlarged, with a right lobe thickness of 139 mm and a left lobe thickness of 78 mm. The echo structure was uneven and heterogeneous, with increased reflection intensity except for boundary areas. Intrahepatic ducts and vessels were not dilated.

A liver function test showed elevated liver enzymes on October 20th, 2015. (Aspartate aminotransferase [AST]—68 U/L [N < 50], alanine aminotransferase—73 U/L [N < 50], alkaline phosphatase—3354 U/L[N30-120]).

Fistulography on October 19, 2015, showed drainage in the right hypochondrium, entering a cavity 11 × 15 mm and contraction 7 × 9 mm, with no contrast discharge into the small intestine. Choledochoscopy was performed on October 20th, 2015, intraoperatively through the common bile duct stump, revealing a blockage in the right lobe of the liver.

Past medical history

The patient suffered from recurrent tonsillitis, recurrent cold and moderate-grade fevers four to five times a year during her childhood. She also developed herpetic rashes 1–2 times a year. She had been suffering from arterial hypertension for 10 years and taking antihypertensive drugs.

Family medical history

Her grandfather was diagnosed with stomach cancer, while her father battled pancreatic cancer, and her aunt had adrenal cancer.

Psychological profile and stresses

The patient had been a reserved person since childhood. Her husband died from complications of diabetes, and she felt guilty that she could not aid him, although she was in the health care profession. She had an aversion to being in the company of people and a negative attitude towards people who consoled her. She often kept sighing.

Diagnosis

Fistula of bile duct (ICD 10: K83.3). ⁴

Case analysis and prescription

Based on the cause and totality of symptoms (shown in Fig. 1), the initial prescription was made to clear the acute layer of pathology. A dose of Staphisagria 200 CH was given on October 22nd, 2015. Staphisagria is one of the important homeopathic remedies for postsurgical situations, including injuries. ⁵

FIG. 1.

Repertorial result on October 22, 2015 (Vithoulkas compass).

FIG. 2.

Repertorial result on October 26, 2015 (Vithoulkas compass).

Follow-up and outcome

The follow-up of the case is provided in Table 1.

Table 1.

Follow-up of the Case

Date	Symptoms	Analysis	Prescription
October 23, 2015	Within 24 h after the remedy, pain at the site of surgery improved. Her appetite and energy levels also improved. Dysuria reduced drastically.	The remedy is acting, and we must wait until we have any new symptoms.	Nil
October 25, 2015	On the third day of taking Staphisagria, bile stopped flowing through the drains installed in the subhepatic space and the right lateral canal. The patient felt much better in general. A Ultrasonography scan and liver function test were repeated. (Table 2) An ultrasound scan of the abdominal cavity suggested the absence of fluid and acute pathology. However, liver function tests still showed elevated levels of enzymes. (AST—696 U/L [(N < 50], ALT—654 U/L [N < 50], ALP—1000 U/L [N 30–120], Gamma-glutamyl transferase [GGT]—637 U/L [N < 40])	The patient’s acute symptomatology improved however the liver enzymes were still elevated showing deterioration of chronic pathology. Hence, we must treat the chronic condition.	Nil
October 26, 2015	The symptoms available for prescription during this follow-up are shown in Figure 2. The patient had a strong history of grief (+++) with an aversion to company (+++) and consolation (++) She had back pain > lying on back (++) lying on something hard (++) She could not tolerate sun (++) and warm weather (++).	The patient’s acute symptomatology improved however the liver enzymes were still elevated showing deterioration of chronic pathology. Hence, we must treat the chronic condition.	Natrum muraticum 200C was prescribed—1 dose each for 3 days.
October 30, 2015	An ultrasound scan of the abdominal cavity suggested the absence of fluid and acute pathology. The laboratory tests indicated that liver enzymes were improving gradually. However, GGTP remained significantly elevated (552 U/L), which also indicated cholestasis. (AST—200 U/L [N < 50], ALT—302 U/L [N < 50], ALP—572 U/L [N 30–120], [GGT]—552 U/L [N < 40])	Patient is doing better pathologically and in general. We must wait for new symptoms to appear.	Nil
November 07, 2015	Two days later, the patient was discharged. Ultrasonography on November 04, 2015, revealed an improved liver examination with clear contours, heterogeneous echo structure, preserved infiltrative changes, postcholecystectomy status, an 11 mm portal vein, homogeneous echo structure, and no liquid inclusions. Drainage was visualized in the subhepatic space. A week after taking the remedy, the patient developed herpetic eruptions on the anterior abdominal wall around the postoperative wound.	Patient has developed old complaint and has better prognosis. We must wait until any symptoms appear.	Natrum muraticum 6X/ 3 weeks.
April 01, 2016	Back pain relapsed. Grief improved drastically.	There is a relapse of symptoms with an indication of the same remedy. We need to repeat the remedy.	The patient was prescribed Natrum muraticum 200 CH, 1 M 1 dose each.
January 01, 2018	The patient’s energy levels improved. She led an active lifestyle. Indigestion improved. She no longer suffered from attacks of paroxysmal tachyarrhythmia. Back pain improved drastically. Blood pressure stabilized. Laboratory tests show improved liver function. (AST—143 U/L [N < 50], ALT—30.2 U/L [N < 50], ALP—26.1 U/L [N 30–120], [GGT]—143 U/L [N < 40]) The patient was on a diet, constantly taking small doses of antihypertensive drugs and occasionally drugs that dilute bile.	Patient is doing better in general and pathologically. We must wait until any clear remedy pattern appears.	Nil
October 28, 2021	The patient did not have any symptoms. She was doing better both emotionally and physically. Laboratory findings also revealed marked improvements. (AST—30.9 U/L [N < 50], ALT—28.5 U/L [N < 50], ALP—92 U/L [N 30–120], [GGT]—147 U/L [N < 40])	The patient is doing better. We need to wait until any new symptoms appear.	Nil.

AST, aspartate aminotransferase; ALA, alanine aminotransferase; ALP, alkaline phosphatase.

The postoperative cystitis improved almost instantly after the remedy, and the BDF healed within the first week after the homeopathic treatment. The case showed gradual restoration in liver function along with overall improvement in general well-being and was followed up for over 6 years.

Discussion

Gallstone disease remains a significant global health concern, with cholecystectomy being the viable conventional treatment. ² Bile duct reconstructions are necessary, but postoperative complications remain a concern. ⁶ Beyond anatomical repair, the functional restoration of normal bile flow and liver function is a crucial aspect that must be addressed. ⁶ Surgical approaches may not always be feasible, prompting the exploration of alternative therapies. In such a critical scenario, homeopathy may serve as an adjunct option. ⁷ Classical homeopathy is a holistic system of medicine that aims to stimulate the body’s innate healing abilities and studies the mental, emotional, and physical symptoms to provide tailored treatment. ⁸

The above patient presented with a BDF following laparoscopic cholecystectomy, leading to a challenging postoperative course. Initial approach involved addressing the postoperative complaints first, followed by the chronic condition. Staphisagria and Natrum muraticum were administered according to the symptomatology, resulting in symptom alleviation, accelerated recovery, and improved liver function. ⁵ Within 1 month after the remedies, the patient’s old complaint returned, suggesting a positive indication during homeopathic treatment.^8,9 “Hering’s Law of Cure,” explained by J.T. Kent, suggests that symptoms, previously suppressed or masked, may reappear temporarily in the reverse order of their appearance during the healing process and indicates a positive response to the homeopathic treatment. ⁹

From a conventional standpoint, such a recovery without a planned hemi-hepatectomy remains challenging to explain. The treating surgeon, a highly experienced hepatologist, initially intended to perform a second-stage operation. However, due to unexpected improvement, no further surgery was required. This unexpected resolution, particularly the spontaneous redirection of bile flow from the right lobe to the left and ultimately into the small intestine, challenges conventional medical expectations and suggests the potential role of homeopathy.

Over 6 years of follow-up, the patient’s impaired liver function showed remarkable improvement and stability. The patient not only sidestepped further traumatic surgeries but also experienced improvement in general health and well-being.

The Modified Naranjo Criteria for Homeopathy causality assessment provided a score of 12/13, suggesting a significant causal relationship between the results and the treatment (Table 2). ¹⁰ This scoring is supported by rapid and sustained improvement in the primary complaint (bilious discharge), resolution of secondary symptoms (fever, cystitis, and fatigue), objective signs of recovery (laboratory investigations and no recurrence over 6 years), and alignment with classical homeopathic principles, including the return of old symptoms and general well-being. The improvement occurred in a plausible timeframe following the remedy, and no other medical intervention was given during this phase, further strengthening the causal inference.

Table 2.

Modified Naranjo Criteria for Homeopathy (MONARCH)—for Causality Assessment

Domains		Yes	No	Not sure or N/A	Score in case	Justification
1	Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed?	+2	−1	0	2	The bile duct fistula healed within a week of homeopathic treatment, and cystitis symptoms improved almost immediately.
2	Did the clinical improvement occur within a plausible timeframe relative to the medicine intake?	+1	−2	0	1	Improvement occurred shortly after the administration of Staphisagria 200 CH.
3	Was there a homeopathic aggravation of symptoms?	+1	0	0	0	No aggravation was reported.
4	Did the effect encompass more than the main symptom or condition (i.e., were other symptoms, not related to the main presenting complaint, improved or changed)?	+1	0	0	1	General well-being, liver function, and psychological symptoms also improved, not just the fistula.
5	Did overall well-being improve? (Suggest using a validated scale or mention about changes in physical, emotional, and behavioral elements)	+1	0	0	1	The patient reported better energy, emotional state, and quality of life over 6 years.
6A	Direction of cure: did some symptoms improve in the opposite order to the development of symptoms of the disease?	+1	0	0	1	Bile duct fistula improved, followed by mental and emotional improvement.
6B	Direction of cure: did at least one of the following aspects apply to the order of improvement in symptoms: from organs of more importance to those of less importance? from deeper to more superficial aspects of the individual? from the top downwards?	+1	0	0	1	Yes, old symptoms returned during treatment, and the patient started developing skin complaints (herpes), which is more superficial compared with the bile duct fistula.
7	Did “old symptoms” (defined as non-seasonal and noncyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement?	+1	0	0	1	The return of old symptoms (herpes) was noted after the initial remedy.
8	Are there alternative causes (i.e., other than the medicine) that—with a high probability—could have produced the improvement? (Consider the known course of the disease, other forms of treatment, and other clinically relevant interventions)	−3	+1	0	1	No concurrent treatment was given at the time of improvement. Prior surgery had failed to resolve the issue.
9	Was the health improvement confirmed by any objective evidence? (e.g., investigations, clinical examination, etc.)	+2	0	0	2	Liver function tests and imaging showed clear improvement posttreatment.
10	Did repeat dosing, if conducted, create similar clinical improvement?	+1	0	0	1	On April 1st, 2016, the patient showed a relapse in back pain. The same remedy (Natrum muriaticum 200 CH, 1 M) was repeated and produced similar clinical improvement, confirming reproducibility. This was not a routine repetition but a relapse after months of remission.
	Total				12

A key limitation of this report is the lack of access to hospital diagnostic records for case publication. Due to institutional policies and medico-legal constraints related to suspected iatrogenic bile duct injury, direct access to imaging and laboratory data before and after treatment was not available. However, the meticulous documentation of the patient’s detailed history, timeline of events, and consistent findings from long-term follow-up supports the credibility of the clinical outcome reported here.

The authors have completed the CARE Checklist for this case report and included it as online supplementary material (Supplementary Table S1). There is a remote likelihood of self-resolution in the above-presented pathology, and therefore, further scientific investigation into the merits of homeopathy in managing bile duct injuries is necessary.

Conclusion

Classical homeopathy may offer a safe and effective alternative to invasive treatments in cases of bile duct injuries, as seen in the case presented here. The positive impact observed in this report requires further research into the role of homeopathy in managing postoperative complications and chronic conditions associated with gallbladder diseases.

Authors’ Contributions

E.I.: Conceptualization and investigation; A.L.: Writing, referencing and editing; S.M.: Visualization, editing, review, and supervision; G.V.: Supervision and validation.