Biloma: A Rare Manifestation of Spontaneous Bile Leak

Abstract

A biloma is an intrahepatic or extrahepatic encapsulated collection of bile outside of the biliary tree and within the abdominal cavity. Hepatobiliary interventions and laparoscopic cholecystectomy are the most common etiologies of biloma followed by abdominal trauma, choledocholithiasis, and biliary dilation secondary to biliary stricture. We report a case of a 91year-old female who presented to the emergency room with an acute onset of epigastric and right upper quadrant sharp pain for one day that radiated to the back, and was associated with two to three episodes of vomiting. Initial abdominal imaging including CT scan, ultrasound and magnetic resonance cholangiopancreatography (MRCP) of the abdomen and pelvis revealed a distended gallbladder with wall thickening, but without evidence of pancreatitis or gallstones. Hepatobiliary iminodiacetic acid (HIDA) scan findings were consistent with extrahepatic biliary leakage into the peritoneum. A cholangiogram demonstrated a perihepatic biloma. A combined approach using fluoroscopic-guided biloma drainage and endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stent placement across the site of the biliary leak resulted in the complete resolution of symptoms. Biloma should be included in the differential diagnosis of right upper quadrant abdominal pain. A high index of clinical suspicion is required for early diagnosis and treatment.

Fístula Biliar Relacionada À Coledocolitíase

“…Existem algumas inconsistências na literatura quando se trata da definição de fístulas biliares espontâneas 5 . Alguns estudos definem como vazamento de bile onde uma causa específica permanece não identificável e geralmente é diagnóstico de exclusão 5,11 .…”

Spontaneous Bile Leak in a Patient Without Recent Abdominal Surgery or Trauma

“…However, a large body of research defines bile leak as a broader term. Using the PubMed search function, a significant amount of literature was found that referred to "spontaneous bile leak," a term used to refer to a leakage of biliary fluid that did not follow surgical intervention of any kind [4,[9][10][11][12][13]. Spontaneous bile leak has been defined as a bile leak "where a specific cause remains unidentifiable and is usually a diagnosis of exclusion" [9].…”

“…Using the PubMed search function, a significant amount of literature was found that referred to "spontaneous bile leak," a term used to refer to a leakage of biliary fluid that did not follow surgical intervention of any kind [4,[9][10][11][12][13]. Spontaneous bile leak has been defined as a bile leak "where a specific cause remains unidentifiable and is usually a diagnosis of exclusion" [9]. One article presented a case similar to ours, of a spontaneous bile leak with no recent surgery, abdominal trauma, or evidence of cholelithiasis or sepsis.…”

Spontaneous cystic biloma after laparoscopic cholecystectomy treated conservatively: A case report

“…Our patient underwent MRCP that found a large epigastric cystic mass full of leaking bile, without any signs of CBD injury. Abdominal imaging, such as abdominal ultrasound (US), multi-slice computed tomography (MSCT), magnetic resonance cholangiopancreatography (MRCP), and Chole-scintigraphy using 99mTc hepatobiliary iminodiacetic acid (HIDA) scan, are crucial to identify biloma and rule out other possible etiologies [ 10 ]. Ultrasound (US) is preferable as the first-level imaging method, since it is non-invasive, fast and easy to perform.…”

“…But the sensitivity of abdominal US is low (70%), though it is used as the initial imaging in the evaluation of biloma. The sensitivity and specificity of CT scan are approximately 90% and those of MRI are above 95% in the detection of biloma and bile leak; however, smaller bilomas can be missed [ 4 , 10 ]. The MRCP sequences are helpful to identify the source of the biliary leak.…”