CASE 12118 Published on 22.08.2014

Post-laparoscopic cholecystectomy abdominal wall biloma

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Shah A¹, Shah R², Heir MK¹ and Botchu R³

^1. Department of Radiology,
University Hospitals of Leicester,
NHS Trust, Infirmary Square,
Leicester, LE1 5WW, UK
² University of Nottingham,
Queen’s Medical Centre,
Nottingham, UK
³ Department of Radiology,
Kettering General Hospital,
Kettering, NN16 8UZ UK

Patient

61 years, male

Categories

Area of Interest Abdomen, Biliary Tract / Gallbladder, Abdominal wall ; Imaging Technique CT, Fluoroscopy

Procedure Education, Cholangiography, Drainage ; Special Focus Pathology ;

Show more Show less

Download as PDF Print Show related cases Notify admin

Clinical History

A 61-year-old man presented with right upper quadrant mass 6 days after laparoscopic cholecystectomy. Contrast-enhanced CT abdomen/pelvis revealed a fluid collection in the right anterolateral abdominal wall and rectus sheath and was treated conservatively as a haematoma. Two-weeks later, the patient was readmitted with pyrexia, malaise and difficulty breathing.

Imaging Findings

Initial CT demonstrated a focal low attenuation homogenous collection within the right anterolateral abdominal wall and right rectus sheath, extending from the costal level down to the inguinal region. A repeat contrast enhanced CT was performed and the previously noted rectus sheath collection had cleared. However, a large amount of ascites with a right subphrenic component could be seen. Subsequent ERCP demonstrated an active focus of contrast extravasation from a small branch of the bile duct of segment 5 of the liver.

Discussion

Encapsulated bile collection outside the biliary tree secondary to spontaneous, iatrogenic or traumatic injury is termed biloma. Bilomas after cholecystectomy are uncommon, reported in up to 2.5% of cases [1], and higher after laparoscopic cholecystectomy in comparison to open cholecystectomy [2]. Bilomas present within the gallbladder fossa, as perihepatic collections or as free peritoneal fluid with an unusual case reported at laparoscopic port sites [3].

Bilomas usually present with non-specific symptoms of abdominal pain, nausea, jaundice and abdominal tenderness. Presentation time is often a few weeks but minor leaks can have a delayed presentation [4], hence, a high index of suspicion is required.

Bilomas are discrete extrahepatic hypoechoic (ultrasound) or hypoattenuating (CT) fluid collection. Bilomas commonly occur in the right upper quadrant and less commonly in the left upper quadrant and lesser peritoneal sac [5]. In the case of our patient, the biloma occurred within the rectus sheath, an unusual location not described in the literature. Hounsfield units for bilomas are usually <20, but can be up to 50HU when mixed with other fluids [5]. The attenuation value of a haematoma is higher than a biloma ranging from 20-75HU. Rectus sheath haematomas have been described following laparoscopic cholecystectomy, predominantly seen in patients on anticoagulation.

Ultrasound and CT can detect fluid collections but cannot accurately differentiate between bile, pus, blood or serous fluid. It is essential to define the nature of the collection and potential source. Though heavily T2-weighted Magnetic Resonance cholangiopancreatograhy (MRCP) can provide anatomical detail of the biliary tree, functional detail requires scintigraphy, but is limited by poor spatial resolution making treatment planning difficult [6]. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) can identify active leaks but are disadvantaged by its invasive nature, associated serious risks and use of radiation. MRCP is non-invasive and radiation-free. Contrast agents specifically excreted in bile can be utilised to demonstrate contrast outside the biliary tree and hence identify the leak. Agents include Multihance, Primovist and Teslascan [7]. Aduna et al [8] report 95% sensitivity and 100% specificity for the detection of bile leak with the use of contrast-enhanced MRCP.

Management includes ultrasound-guided paracentesis with/or without a pig-tail catheter for continuous drainage. A biliary stent can be deployed during ERCP to promote internal biliary drainage.

Good clinical information and a high index of suspicion are imperative in diagnosing bilomas early. The density of collections help guide appropriate differential diagnosis even when presenting in unusual locations.

Differential Diagnosis List

Abdominal wall biloma after laparoscopic cholecystectomy.

Haematoma

Abscess

Post-operative seroma

Final Diagnosis

Abdominal wall biloma after laparoscopic cholecystectomy.

References

[1] Kozarek R, Gannan R, Baerg R et al. (1992) Bile leak after laparoscopic cholecystectomy. Diagnostic and therapeutic application of endoscopic retrograde cholangiopancreatography. Arch Intern Med 152: 1040-1043 (PMID: 1533759)

[2] Morgenstern L, Berci G, Pasternak, EH. (1993) Bile leakage after biliary tract surgery. Surgical Endoscopy 7: 432- 438 (PMID: 8211625)

[3] Festekjian JH, Hassantash SA, Taylor EW. (1997) Abdominal wall biloma: An unusual complication of laparoscopic cholecystectomy. JSLS 1: 353-355 (PMID: 9876703)

[4] Kannan U, Parshad R, Regmi SK. (2009) An unusual presentation of biloma five years following cholecystectomy: a case report. Cases J 10;2:8048 (PMID: 20181203)

[5] Vazquez JL, Thorsen MK, Dodds WJ et al. (1985) Evaluation and treatment of Intra abdominal Bilomas. AJR 144:933-938 (PMID: 3885693)

[6] Barkun AN, Rezieg M, Mehta SN, et al. (1997) Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group. Gastrointest Endosc 45:277–282. (PMID: 9087834)

[7] Mungai F, Berti V, Colagrande S. (2013) Bile leak after elective laparoscopic cholecystectomy: Role of MR imaging. J Radiol Case Rep 7(1): 25–32. (PMID: 23372872)

[8] Aduna M, Larena JA, Martín D, Martínez-Guereñu B, Aguirre I, Astigarraga E. (2005) Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP. Abdom Imaging 30(4):480-7 (PMID: 15688109)

Case information

URL:	https://www.eurorad.org/case/12118
DOI:	10.1594/EURORAD/CASE.12118
ISSN:	1563-4086

Figure 1

Hypodense collection in the right anterolateral abdominal wall and rectus

Axial CT with intravenous contrast in portovenous phase (70 sec delay) demonstrating low density fluid in the right anterolateral abdominal wall and right rectus sheath (*).

Figure 2

Hypodense collection in the right anterolateral abdominal wall and rectus

Axial CT with intravenous contrast in portovenous phase (70 sec delay), demonstrating an average of 3 Hounsfield Unit of the right abdominal wall collection.

Figure 3

Repeat CT resolved abdominal wall collection with new ascites

Axial CT with intravenous contrast in portovenous phase (70 sec delay) demonstrating resolution of the right rectus sheath collection with a new large ascites (*) and right subphrenic collection (x) with an average of 5HU.

Figure 4

ERCP with extravasation

ERCP image demonstrating contrast extravasation in keeping with biliary leak into the abdominal wall (curved arrows). The percutaneous drain is in situ (straight arrows).

Figure 5

Initial percutaneous drain

Coronal CT with intravenous contrast in portovenous phase (70 sec delay) demonstrating the percutaneous drain (arrow) in situ in the right hypochondrium with large ascites (*).

Figure 6

Post drainage and internal biliary stent

Coronal CT with intravenous contrast in portovenous phase (70 sec delay) demonstrating the biliary stent (long arrow) with near total resolution of ascites and right sub-diaphragmatic collection. The pig tail catheter is also demonstrated (small arrow).