Double giant chronic bilomas with late presentation—9 years after cholecystectomy

Abstract

Dear Editor, We have the intention to report of a 68-year-old man with very late presentation of two well-encapsulated giant bilomas. They occurred 9 years after open cholecystectomy, performed for an acute calculous cholecystitis. Early and late postoperative course was absolutely uneventful. Nine years later, few days before actual admission, he felt unclear symptoms of abdominal pressure and discomfort. Clinical examination and ultrasonography (US) showed large cystic masses in the right and left part of the abdomen. Computed tomography (CT) density values were 16 Hounsfield units (HU). At first, we suspected on the extrapancreatic pseudocysts. However, the pancreas was normal on the CT. At magnetic resonance imaging (MR), lesions were heterogeneously intense (T1) and homogenously hyperintense on the T2-weighted images (Figs. 1 and 2). Magnetic resonance cholangiopancreatography (MRCP) showed a normal biliary tree, with no strictures or stones and without any communication. Analysis of percutaneous needle aspirate showed clear bile with no cellular structures and bilirubin concentration of 680 mcm/L. The bilomas measured in total 5.2 L of the stagnant bile. The smaller one (16.3×10.7 cm) was located in the right part of the abdomen, into the subhepatic space and right paracolic gutter. The bigger one (22.7×11.2 cm) occupied left subphrenic space with propagation into the left paracolic gutter. Because of the failure of percutaneous drainage (incomplete drainage of the left biloma despite of the two repositioning of the drainage catheter), the patient was operated on, with simple surgical drainage. Surgical exploration and intraoperative cholangiography showed a normal biliary tree. The patient remains symptom-free with normal clinical and laboratory data more than 12 months after surgery.

Late Presentation of Chronic-Organised Biloma Masquerading as Gallbladder Fossa Mass Years After Cholecystectomy: a Diagnostic Enigma

“…In our case, however, it actually resembled a mass. Stojanovic et al reported giant bilomas 9 years after cholecystectomy treated by percutaneous and surgical drainage [1]. Similar to our case, biliary system was normal.…”

“…Pathogenesis of chronic biloma remains obscure. Lack of initial symptoms could be due to slow collection of small amount of sterile bile from minor biliary injury, which might have closed spontaneously in absence of biliary obstruction [1,6]. In our case, the long duration of biloma lead to resorption of fluid, resulting in thick inspissated sludge.…”

“…Some patients have delayed presentation, weeks to months after cholecystectomy, with intra-abdominal bile collection known as BBiloma^. Bilomas presenting years after surgery are extremely rare, with only four cases reported in literature [1][2][3][4]. We present a case of chronic-organised biloma mimicking gallbladder fossa mass years after cholecystectomy.…”

An unusual presentation of biloma five years following cholecystectomy: a case report

“…Quite unusual of its kind, our case presented about 5 years following an uneventful open cholecystectomy and therefore it was not suspected as the cause of right hypochondrial lump. Literature review shows only one report of such a delayed presentation [5]. Probable reason for such a delayed presentation in our case could be a minor leakage following bile duct injury during cholecystectomy, which initiated a low grade inflammation and gradually walled off.…”

“…Probable reason for such a delayed presentation in our case could be a minor leakage following bile duct injury during cholecystectomy, which initiated a low grade inflammation and gradually walled off. The other hypothesized reasons reported for delayed presentations are low secretory pressure (< 30 cm of water) and low osmolality of the leaked bile [5]. …”