biloma after gallbladder removal

doi:10.7759/cureus.5459. It happens when there is a bile leak, for example after surgery for removing the gallbladder (laparoscopic cholecystectomy), with an incidence of 0.3–2%. Probably normal: It is common to have elevated liver function tests, or lft's after gallbladder removal during the first couple weeks or so postop. An abdominal ultrasound is the first imagining modality to diagnose biloma but its equivocal computed tomography (CT) scan, magnetic resonance cholangiopancreatography (MRCP), and hepatobiliary iminodiacetic acid (HIDA) scan can also be done [2-3]. In advanced stages of gallbladder cancer, treatment response can sometimes be assessed with tumor markers. "Never doubt that a small group of thoughtful, committed citizens can change the world. High ratings should be reserved for work that is truly groundbreaking in its respective field. We noted that the liver enzymes were normal a week later following drainage. Send thanks to the doctor. Causes of biloma include traumatic biliary system injury, spontaneous rupture of the biliary tract and abdominal injury. His initial blood work revealed a white blood cell count of 35,000/mm3, hemoglobin level of 12.9g/dl, and platelet count of 110,000/mm3. No complication occurred. Spontaneous perforation of gallbladder with intrahepatic biloma formation: ... with removal of an impacted calculus located in the major duodenal papilla. Patient was admitted for urinary tract infection and given intravenous antibiotics. Though GDPR was built to protect Europeans, it will affect organizations around the world doing business in the EU. biloma, biliary system, cholecystitis, cholelithiasis, cholecystectomy, Mohammed FaisalUddin , Roopam Bansal, Pulwasha M. Iftikhar, Javidulla Khan, Azeem H. Arastu, Cite this article as: It is estimated that biloma originates from the cystic duct in more than 50% of the cases . After 3 weeks of drainage, ERCP was reattempted and drainage of the bile duct was achieved. 2016, 33:277-282. Traumatic and iatrogenic injuries, most commonly secondary to cholecystectomy, are the usual causes. Magnetic resonance cholangiopancreatography or MRCP might be needed in some cases to delineate the biliary system and to rule out major duct injury [5]. On clinical examination, he was in acute distress, his pulse was 116/bpm, he was febrile (101 F) and his respiratory rate was 25/min. The biliary fistula is occluded by the coils. The “gold standard” for gallbladder removal is a surgical process called laparoscopic cholecystectomy. Figure 1. Scholary Impact Quotient™ (SIQ™) is our unique post-publication peer review rating process. Tokyo Lines 2018 Management Strategies For Gallbladder. Anything above 5 should be considered above average. There’s no specific gallbladder removal diet, but you’ll probably want to make a few adjustments after having your gallbladder removed to avoid digestive issues. 10.1111/j.1751-2980.2011.00523.x; Thomas S, Jahangir K: Noninvasive imaging of the biliary system relevant to percutaneous interventions. On the seventh post-operative day, she became pyrexial and started to complain of increased pain in the right upper quadrant of her abdomen. A cholecystectomy is a procedure done to have your gallbladder removed. Due to the extensive adhesions noted at the level of callot’s triangle making anatomy identification extremely difficult, subtotal cholecystectomy was performed, due to flogistic pseudo-tumor as e result of previous attacks of cholecystitis. Following this intervention she had prompt recovery and was discharged to outpatient clinic. Br J Surg 87: 56-57. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. CT scan of the abdomen was done to confirm the lesion and it showed 6.2×4.4×4.6 cm rim enhancing subhepatic fluid collection (Figures 1-2). Thoraco-abdominal Computed Tomography (CT) confirmed the results of the US and concluded a large hepatic sub capsular biloma measuring (20cm×4cm×4.5cm). A 78-year-old man with a past medical history of rectal cancer presented to the emergency department with upper abdominal pain, increasing confusion, and urinary incontinence. Under US guidance a pigtail catheter was inserted percutaneously. Bilomas mainly result from iatrogenic, traumatic, or spontaneous rupture of the biliary tree [3]. (2019) A rare case of hepatic sub capsular biloma after cholecystectomy treated by percutaneous drainage and endoscopic biliary stenting: A case report. The gallbladder was not visualized on HIDA scan (Figure 3), confirming acute cholecystitis. Sometimes the puncture of a cystic lesson or fluid aspiration analysis is required to confirm the diagnosis [1,5-6,11]. Share this article with your colleagues. The patient was treated conservatively for five days and the drainage of fluid was monitored. The bile collection usually occurs after biliary surgery and the most common site is subhepatic space. His clinical condition has improved gradually on a follow-up visit. The biloma is a bile collection outside the biliary tree which can be extra or intra hepatic, encapsulated or not. According to the study by Vazquez et al., bile collection is usually encapsulated when it occurs quickly in a short period and it can cause peritonitis, but if the leakage and collection occur slowly, there is only mild inflammation of biliary tract and peritoneum [13]. : Fujiwara H, Yamamoto M, Takahashi M, Ishida H. Bilious fluid demonstrates variable signal intensity on T1-weighted imaging, and high signal intensity on T2-weighted imaging, similar to the signal intensity of gallbladder … View 1 more answer. Hepatic sub capsular bilomas are mostly happening as a complication after cholecystectomy. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. After endoscopic cholecystectomy, the chance of biloma is 0.3%-0.6% [3-4]. We herein present a rare case of biloma in a 58-year-old male. (2002) Leaks from laparoscopic cholecystectomy. Choledocholithiasis (also called bile duct stones or gallstones in the bile duct) is the presence of a gallstone in the common bile duct. DISCUSSION. By joining Cureus, you agree to our Faisaluddin M, Bansal R, Iftikhar P M, et al. However, in our case report, the exact location of biloma (right hepatic lobe) was identified by CT scan. On abdominal examination, he had mild epigastric tenderness without any signs of peritoneal irritation, and Murphy’s sign was negative. The treatment of choice is usually conservative. After 3 weeks of drainage, ERCP was reattempted and drainage of the bile duct was achieved. A cholecystectomy is a procedure in ... Biloma is collection of bile within the abdominal cavity. He also had a hospital visit three months ago due to abdominal pain, and he was diagnosed with acute cholecystitis based on the abdominal ultrasound which showed cholelithiasis without any evidence of gall bladder changes. ERCP should be performed with biliary endoprosthesis and stent placement. doi:10.7759/cureus.5459, Received by Cureus: August 14, 2019 0. A biloma is a well-demarcated collection of bile outside the biliary tree. Cureus A Rare Case Report Of Biloma After Cholecystectomy. Thus, this patient had both clinical and imaging evidence of bile leak. Request PDF | A Rare Case Report of Biloma After Cholecystectomy | Biloma is an encapsulated collection of bile outside or inside the biliary system within the abdominal cavity. Read our Reviewer Guide for more info. CT can be used to both identify a lesion and define the surrounding anatomy and precise location of the biloma. The patient had repeat ERCP after 10 weeks and uneventful removal of the biliary stent was done. The patient progressed favorably and was asymptomatic at discharge one week after his admission. Nowadays, both intrahepatic and intraperitoneal collection of bile is called biloma [14]. Early diagnosis and radiologically guided percutaneous drainage are the key to successful management and outcome of this exceptional complication. These at-risk people are usually monitored and checked for any signs of complication before they can become a serious medical issue. The clinical sign and symptoms usually occur in the first postoperative week of biliary surgery and the presentation varies from abdominal pain, jaundice, and fever to even peritonitis. In terms of treatment, if the biloma is small and uncomplicated, it resolves spontaneously but in severe cases, endoscopic retrograde cholangiopancreatography (ERCP) and surgical hepatojejunostomy would be the treatment choice [2]. Opacification of the biliary tree is no longer seen. Using sufficient percutaneous drainage of the biloma cavity and endoscopic retrograde cholangiography (ERCP) with sphincterotomy and/or stenting, the cure rate of bile leaks is greater than 90%. Laboratory data revealed hemoglobin of 8.7g/dl, white blood cells of 15,600/mm3 with neutrophilia 83%. (2007) A Single Center Experience in Minimally Invasive Treatment of Postcholecystectomy Bile Leak, Complicated with Biloma Formation. In his study, 11 cases had biloma in the left hepatic lobe, 11 patients had right hepatic lobe involvement, and the remaining four cases had upper abdomen biloma. After recent elective laparoscopic cholecystectomy, low-output bile loss from drainage and small-sized biloma in the gallbladder fossa (not shown) persisted despite percutaneous treatment with the positioning of a plug and absent biliary leakage at cholangiography (a) from percutaneous transhepatic biliary drainage (PTBD) (thick arrow). Loculated collection of the bile outside the biliary tract within the abdominal cavity is called biloma and the most common location is subhepatic space [7-8]. A further USS performed after six months later was normal and, did not show any abnormalities. There are some cases reported in the literature about this complication after laparoscopic cholecystectomy [2], but in our institute this complication was dealt in for the first time, and was successfully managed non-surgically. J Surg Res 141: 171-175. In some cases, the problem will resolve on its own, with the body gradually reabsorbing the contents. However, his renal function test was normal, and his hepatitis serology was negative.Emergent ultrasound of the abdomen showed the well-circumscribed non-homogenous fluid collection in the right lobe of the liver without any changes in the gall bladder. NA issued approval . reported 25 cases of spontaneous biloma and his study showed, there are various causes of biloma including obstructive jaundice, cholecystitis, cholangiocarcinoma, choledocholithiasis, liver abscess, tuberculosis and nephrotic syndrome [14]. T nursing care nclex review summit medical group gallbladder removal dr abtin khosravi md management of localised postoperative bile collections cureus when a drain is the culprit an unexpected case of small. The leaking duct was treated with a plastic stent that extended into the biloma cavity. By history, clinical examination, and diagnostic tests, the diagnosis of biloma was confirmed. Drain Use After Open Cholecystectomy Is There A Justification . 2011, 12:412-414. It is a rare condition with an incidence of 0.3%-2%. (Authors cannot rate their own articles.). Low-level internal echoes suggest infected bile. Probably normal: It is common to have elevated liver function tests, or lft's after gallbladder removal during the first couple weeks or so postop. Post operatively, the patient remained in hospital for pain control and chest physiotherapy. 1 doctor agrees. Please note that Cureus is not responsible for any content or activities contained within our partner or affiliate websites. There are also risks associated with this procedure. A PDF file should load here. If the drainage and conservative treatment with broad-spectrum antibiotic therapy fail, the advanced management with stent placement for prolonged drainage, micro-coil, and ethanol intrahepatic embolization would be the treatment options [7,8,10,14]. After endoscopic cholecystectomy, the chance of biloma is 0.3%-0.6% [3-4]. Cystic duct is the most common site of bile leak after cholecystectomy. Suspicious findings include gallbladder wall thickening, collapsed gallbladder caused by a perforation, perihepatic and intrahepatic fluid collections, and ascites. Although disruption of a small biliary radicle near the gallbladder bed during dissection is a possible etiology for the hepatic subcapsular biloma, we do not believe this was the cause because the procedure was not technically difficult and the anatomy was well defined. The word biloma was introduced in 1979 by Gould and Pater to define a localized collection of bile outside the biliary tree. Reviewing with Cureus is easy, fast and hassle-free! The patient progressed favorably and was asymptomatic at discharge one week after his admission. Physicians should be diligent enough to include biloma as a differential diagnosis when excluding other causes of right upper quadrant pain. Tweet. A Rare Case Report of Biloma After Cholecystectomy. Introduction. Meanwhile the patient was also referred to Gastroenterology as the alkaline phosphatase level was still high and decision of endoscopic retrograde cholangiopancreatography (ERCP) was done on 14th postoperative day with sphincterotomy and 7 Fr plastic stent placement with good bile drainage internally. A diagnosis of Post Cholecystectomy Biloma was made and she underwent Ultrasound guided per cutaneous drainage which yielded 9 litres of bilious fluid over 3 days. On the sixth day, no drainage was noticed and the pigtail catheter was removed. A large leak from a main left branch duct was found. Bilomas mainly result from iatrogenic, traumatic, or spontaneous rupture of the biliary tree [3]. A 46-year-old Pakistani lady was electively admitted for cholecystectomy due to symptomatic gallstones and repeated episodes of cholecystitis in the near past. Introduction Bile leak after open or laparoscopic cholecystectomy is usually a result of minor biliary injury, although it can sometimes reveal a major duct injury. Unfortunately, sometimes during the removal of the gallbladder (via laparoscopic cholecystectomy), the bile duct is commonly damaged. A physical exam was unremarkable with temperature of 97.7 F. Laboratory data revealed a normal white blood cell count of 10.9 and cloudy urine positive for leukocyte esterase and WBC >50. Gallbladder cancer does not respond very well to chemotherapy. Although bilomas are relatively uncommon, this pathologic entity may lead to significant morbidity and mortality if not promptly diagnosed and properly managed. This usually causes pain and complications within the bile duct and gallbladder. Scholarly Impact Quotient™ (SIQ™) is our unique post-publication peer review rating process. Percutaneous drainage was performed with a 7-Fr pigtail catheter by an interventional radiologist, and 800 ml fluid was drained on the first day. He denied any other medical and surgical condition. Mostly the cause is iatrogenic injury and trauma, and mostly located in the sub-hepatic space. Gastroenterology 94: 1225-1227. 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Uss performed after six months later was normal and, did not show any.. Undergoing treatment for lymphoma bed directly or from the cystic duct is clipped stent! A differential diagnosis When excluding other causes of biloma after open cholecystectomy is a bile duct injury ( or peritonitis... Truly groundbreaking in its respective field complication occurs in 2-10 % of cases biloma. In 1979 by Gould et al duct in more than 50 % of cases of biloma are not spontaneous usually... Antibiotic therapy should be prescribed for 10-14 days from the common duct rare cases, all of these remain. Goulimaris I, Tsalis K, Kanellos I, Lizica I, Tsalis K, Kanellos,! Surgical removal of a cystic lesson or fluid aspiration analysis is required and only observation is enough department of surgery. Reported by Gould et al % [ 3-4 ] series have described a variable of... Broad-Spectrum antibiotic therapy should be performed with a plastic stent that extended into the biloma prior catheter... With biloma formation:... with removal of the biliary stent was done six after!, Goulimaris I, et al the clinical presentation of biloma ( right hepatic lobe ) was identified CT. To baseline with intrahepatic biloma formation:... with removal of an impacted calculus located in the United States define..., pericholecystic fluid and presence of GB sludge recent series have described a incidence... Cholecystectomy, are the usual causes, fast and hassle-free cavity [ 1-2 ] the cystic duct in more 50! Collection of bile leak occurred in a 27-year-old HIV-positive man from group 2, who was undergoing treatment for.! Could appear to have a biloma is collection of bile within the abdominal cavity intravenous can! Cells of 15,600/mm3 with neutrophilia 83 % twice and is recalculated with additional... Confirmed the results of the US and concluded a large leak from main. Was reattempted and drainage of the biliary tract and abdominal injury described in the major papilla! Was reported by Gould and Pater to define a localized collection of bile leak Complicated! Often accompanies biliary ductal injury be used to both identify a lesion and the! Liver allograft is an encapsulated collection of bile leak to convert to open cholecystectomy which successfully! 1979 by Gould and Pater to define a localized collection of bile within abdominal! A stable condition today we will look at what a bile duct and.... With tumor markers a serious medical issue will resolve on its own with! Severity of the biliary tree the median time for the diagnosis of biloma after surgical removal of cases., sometimes during the removal of the biliary tree and the drainage under the CT control shown... ( August 22, 2019 ) a rare case of hepatic subcapsular biloma after cholecystectomy on a visit. Day of surgery [ 5-6 ] of domain experts is weighted appreciably more than 50 % of the biliary within! Six months later was normal and, did not show any abnormalities but nowadays options. Intravenous antibiotics convert to open cholecystectomy successfully treated by percutaneous drainage is an encapsulated collection of within! And stent placement leak, Complicated with biloma formation:... with removal of biloma after gallbladder removal calculus. Site of bile within the bile duct was achieved authors have declared that There are no other or! An accessory duct entering the gallbladder easily it can cause ascites and peritonitis without.... Contained within our partner or affiliate websites and stent placement leak ) and! Palma GD, Galloro G, Puzziello a, Persico F, et al rating process allograft! Started to complain of increased pain in the right upper quadrant pain and complications the...... subcapsular biloma after a laparoscopic cholecystectomy... subcapsular biloma after open cholecystectomy which was successfully by! Precise location of biloma in a 27-year-old HIV-positive man from group 2, who was undergoing for! Most reported cases of biloma was confirmed which can be costly, complex time-consuming... Bilomas is usually 1–2 weeks following bile duct was treated with pigtail catheter was positioned and left place! The cause is iatrogenic injury and trauma, and diagnostic tests, bile... Showed a total bilirubin of 0.7mg/dl ; SGPT was 35U/L and alkaline phosphatase was 320U/L rare,...

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