Spontaneous Biloma: A Case Report and Literature Review

Bilomas are collections of bile outside the biliary tree. The most frequent etiologies are iatrogenic and trauma. Cases of spontaneous or atraumatic bilomas are rare. Management of bilomas depends on the size and location and may include monitoring only; if the size is < 4 cm, there may be percutaneous or endoscopic intervention. The use of antibiotics depends on the clinical status of the patient. We describe the case of a man who presented with a spontaneous biloma eight years after laparoscopic cholecystectomy and, in addition to signs of choledocholithiasis, a stricture of the common bile duct. In patients with symptoms of biliary pathology, the diagnosis of biloma should be considered even without a history of trauma or recent surgery to initiate appropriate treatment early. Many cases are asymptomatic and resolve spontaneously but occasionally require percutaneous or endoscopic management.

Los biliomas son colecciones de bilis fuera del árbol biliar. Las etiologías más frecuentes son la iatrogenia y el trauma. Los casos de biliomas espontáneos o atraumáticos son poco frecuentes. El manejo de los biliomas depende del tamaño y la localización y puede incluir vigilancia solamente, si el tamaño es < 4 cm, puede haber intervención percutánea o endoscópica. El uso de antibióticos depende del estado clínico del paciente. Presentamos el caso de un hombre que presentó un bilioma espontáneo 8 años después de una colecistectomía laparoscópica que, además de signos de coledocolitiasis, presentaba una estenosis del conducto biliar común. En los pacientes con clínica de patología biliar debe considerarse el diagnóstico de bilioma aun en los casos que no presenten antecedente de trauma o cirugía reciente con el fin de iniciar el tratamiento adecuado tempranamente. Muchos casos son asintomáticos y se resuelven espontáneamente, pero en ocasiones requieren manejo percutáneo o endoscópico.

Posttraumatic biloma formation: diagnosis and management

One of the rarest complications of the hepatic trauma is a biloma, defined as an abnormal bile collection outside the biliary tree, with intra or extrahepatic localization. Patients with biloma do not present with specific clinical features, which demands a challenging radiological diagnosis. In this report, we present a case of biloma due to blunt hepatic trauma, in which the patient experienced a changing symptomatic spectrum after surgery and had an interesting radiological investigation. The clinical course, imaging features, and management of this case are discussed. (AU)

The clinical features and treatment of liver abscess formation after TACE for metastatic liver tumors / 介入放射学杂志

Objective To investigate the clinical features,related risk factors,the efficacy and safety of clinical management about liver abscess formation occurring after transcatheter arterial chemoembolization (TACE) for metastatic liver cancer.Methods Among 1812 patients with metastatic liver tumors who were receiving TACE,23 patients developed liver abscess.The clinical features and risk factors for abscess formation were retrospectively analyzed.The curative effects and safety of percutaneous puncture cavity drainage (PCD),or combined with percutaneous transhepatic cholangiography and drainage (PTCD) were analyzed.Results The incidence of liver abscess after TACE for metastatic liver tumors was 1.3％ (23/1812).Postoperative high fever,chill,elevated white blood cell count and increased neutrophil proportion were the main clinical features of liver abscess.The mean time before the diagnosis of liver abscess was confirmed was (11.3±3.7) days after TACE.The hepatic metastatic malignancy originated from the malignant tumor of digestive tract was seen in 73.9％ of patients,18 patients (78.3％) had a history of gastroenteric surgery,and 12 patients (52.2％) had a history of diabetes mellitus.The number of hepatic metastatic lesions was more than 3 in 19 patients (82.6％).After the formation of liver abscess,the liver functions became worse in all patients (P=0.024).In 19 patients (82.6％),angiography showed that the metastases were hypovascular lesions.Blood and pus cultures revealed that E.coli was the main infectious bacteria of liver abscess.The mean time of using anti-infective drugs before hepatic abscess developed liquefaction was (10.4±3.3) days,and the mean time of abscess liquefaction was (15.9±3.7) days.The mean value of the maximum diameters of abscesses was (9.2±2.0) cm.PCD was employed in all patients,the average times of PCD procedure was (3.7±1.7) times.PCD followed by PTCD was performed in 7 patients as they had biloma associated with obstructive jaundice.The average drainage time for liver abscess was (3.1 ±1.7) months.No infectious peritonitis,tumor rupture,or tumor implantation at puncture point was observed.The median survival time of 23 patients with liver abscess was (8.0±0.7) months.The median survival time in patients who received PCD procedure only was (9.0±1.0) months,while it was (5.0±0.7) months in patients who received PCD together with PTCD,and statistically significant difference in the median survival time existed between the above two groups (P=0.041).Conclusion The risk factors of liver abscess formation after TACE in patients with metastatic liver tumors include the site of primary tumor and gastrointestinal surgery.Diabetes may be one of the risk factors.Clinically,the lesions of liver abscess are usually multiple and they often occur in hypovascular lesions with central necrosis,The nain infectious bacteria are from digestive tract,and biloma is easy to develop.Active and effective antibiotic treatment plus puncture drainage of abscess cavity,or combined with PTCD,are effective treatment measures for this kind of liver abscess.

Bilioescroto secundario a bilioma retroperitoneal como presentación extremadamente rara de fuga biliar espontánea / Biliscrotum secondary to retroperitoneal biloma, as an extremely rare presentation of spontaneous bile leak

Objetivo. Presentar el segundo caso descrito en la bibliografía de bilioescroto secundario a bilioma retroperitoneal espontáneo y mostrar a su vez de manera escalonada el tratamiento que se le suministró hasta la resolución completa del cuadro. Caso clínico: Varón de 69 años que debutó con dolor escrotal derecho en relación con bilioescroto secundario a bilioma retroperitoneal espontáneo. Discusión: El bilioma retroperitoneal es un hecho poco habitual; generalmente se debe a complicaciones quirúrgicas o de procedimientos invasivos (intervencionismo radiológico, CPRE y esfinterotomía endoscópica), aunque puede ser consecuencia de roturas espontáneas de la vesícula o la vía biliar principal. La bilis en el retroperitoneo puede discurrir hasta el escroto, originando la rara entidad conocida como bilioescroto. Generalmente se presenta simulando una hernia inguinal incarcerada. No existe un manejo estandarizado de esta patología ya que está escasamente descrita.

Objective: To present the second case described in the literature of biliscrotum secondary to spontaneous retroperitoneal biloma and show a sequential treatment that we provided until complete resolution. Clinical case: We report the case of a man 69 years old, who debuted with right scrotal pain related to biliscrotum secondary to spontaneous retroperitoneal biloma. Discussion: The retroperitoneal biloma is a rare event, usually due to surgical or invasive procedures complications (radiological interventionism, ERCP and endoscopic sphincterotomy), although it may be the result of spontaneous rupture of the gallbladder or bile duct. Bile in the retroperitoneum may extend into the scrotum, causing the rare condition known as biliscrotum. Usually it occurs simulating an incarcerated inguinal hernia. Does not exist a standardized management of this condition because is poorly described.

Clinical and CT manifestations of iatrogenic hepatic subcapsular biloma / 实用放射学杂志

Objective To investigate the clinical and CT manifestations of iatrogenic hepatic subcapsular biloma (HSB).Methods Seven cases with iatrogenic HSB confirmed by paracentesis in our hospital,and 18 reported in literatures were enrolled into this study.Their clinical and CT manifestations were retrospectively analyzed.Results Of the 25 cases,9 were secondary to laparoscopic cholecystectomy (LC),5 were secondary to percutaneous transhepatic choleductus drainage (PTCD),4 were secondary to percutaneous transhe-patic removal of bile duct stones,2 were secondary to open cholecystectomy,and 5 were secondary to other surgeries.CT showed localized or diffused hepatic subcapsular fluid collection with crescent-shaped or sac-shaped.The hepatic volume decreased and the surface was compressed in some of the cases with diffused fluid collection.Conclusion When localized or diffused hepatic subcapsular fluid collection was detected in CT imaging after liver or gallbladder surgeries (especially LC and PTCD),HSB should be considered.Paracentesis should be performed as soon as possible.

Post Laparoscopic Cholecystectomy Biloma in a Child Managed by Endoscopic Retrograde Cholangio-Pancreatography and Stenting: A Case Report / 대한소아소화기영양학회지

Laparoscopic cholecystectomy, though an uncommon surgical procedure in paediatric age group is still associated with a higher risk of post-operative bile duct injuries when compared with the open procedure. Small leaks from extra hepatic biliary apparatus usually lead to the formation of a localized sub-hepatic bile collection, also known as biloma. Such leaks are rare complication after laparoscopic cholecystectomy, especially in paediatric age group. Minor bile leaks can usually be managed non-surgically by percutaneous drainage combined with endoscopic retrograde cholangio-pancreatography (ERCP). However, surgical exploration is required in cases not responding to non-operative management. If not managed on time, such injuries can lead to severe hepatic damage. We describe a case of an eight-year-old girl who presented with biloma formation after laparoscopic cholecystectomy who was managed by ERCP.

Posttraumatic biloma in 46 cases / 中华普通外科杂志

Objective To probe the causes,early recognition and effective therapy of posttraumatic biloma.Methods The data of all patients with the injury of the liver and bile duct treated in our center during the past 10 years were reviewed.Patients,diagnosed with biloma were retrospectively analyzed in respects of sex,age,cause of biloma,methods and efficacy of diagnosis and treatment.Results There were 46 patients with biloma.Of them,40 were found after liver trauma of grade Ⅲ-Ⅴ.The incidence of biloma was 15.2％ (40/263).In grade Ⅳ,Ⅴ,and Ⅲ,it was 22.6％ (31/137) and 7.1％ (9/126) respectively (x2 =12.20,P ＜ 0.01) and in blunt and penetrating injury,it was 19.3％ (35/181) and 6.1％ (5/82) respectively (x2 =7.67,P ＜ 0.01).Of these 40,36 were found during the course of conservative therapy of severe liver trauma; and 4 were found after laparotomy for the liver trauma.The remaining 6 cases of biloma had a history of injury to extrahepatic bile duct with a incidence of 18.8％(6/32).All 46 patients received spiral CT scaning plus MRI in 9,and ERCP in 11.Of those 40 with biloma after severe liver trauma,28 were cured by ultrasound-guided or computed tomography scan-guided pigtail drainage; and the remaining 12,in whom the biloma volume ＜ 30 cm3 resolved spontaneously.Six patients in whom the biloma as a result of injury to extrahepatic bile duct were cured by surgical intervention.There was no death and complication related with the therapy of biloma.Conclusions Attention should be given to biloma formation,when nonoperative therapy is exercised for severe liver trauma.Ultrasound-or CT scan-guided pigtail drainage is an effective option,but those due to injury of extrahepatic bile duct require surgical intervention.

Bilioma espontâneo: relato de caso e revisão da literatura / Spontaneous biloma: a case report and literature review

Bilioma é qualquer coleção de bile fora das vias biliares. Geralmente, resulta de complicações cirúrgicas e trauma abdominal. A ocorrência espontânea é rara, ocasionalmente associada a coledocolitíase. Relata-se um caso de bilioma espontâneo, cujo diagnóstico foi confirmado radiologicamente. À laparotomia, observou-se bilioma retroperitoneal. A colangiografia transoperatória não evidenciou fístula. Após drenagem, o paciente teve boa evolução e alta hospitalar.

Biloma is defined as any collection of bile outside the biliary tree, usually resulting from surgery complications and abdominal trauma. Spontaneous occurrence of bilomas is rare, occasionally associated with choledocolithiasis. The present report describes a case of spontaneous biloma, whose diagnosis was radiologically confirmed. At laparotomy, the presence of a retroperitoneal biloma was observed. Intraoperative cholangiography has not demonstrated the presence of fistula. After drainage, the patient progressed well and was discharged.

Hepatic biloma in the elderly: our experience on 6 patients / 中华肝胆外科杂志

Objective To retrospectively review our experience of treating hepatic biloma in the elderly.Methods Before cyst fenestration,the fistulas between the bile duct and biloma were ligated in the 6 patients.Result All the 6 patients were cured.On follow-up,there was no recurrence.Conclusion The procedure is feasible and safe in the treatment of biloma in the elderly.

Segmental bile duct leakage after hepatic resection managed with percutaneous ablation by N-butyl cyanoacrylate

A biloma is a rare abnormal accumulation of intrahepatic or extrahepatic bile caused by a traumatic or spontaneous rupture of the biliary tree. The reported incidence of postoperative biloma ranges from 4.8% to 7.6%. Biliary drainage is usually important and necessary for the treatment of biloma, but sometimes bile leakage fails to improve despite prolonged conservative drainage. We report a case of postoperative refractory biliary leakage managed with percutaneous ablation by N-butyl cyanoacrylate.

Spontaneous Biloma Caused by Pancreatic Cancer and Treated by Endoscopic Biliary Stenting / 대한소화기내시경학회지

Biloma is a rare disorder, and is defined as an abnormal extrahepatic or intrahepatic collection of bile within a defined capsular space. The common causes of biloma are iatrogenic and trauma. Spontaneous biloma, especially caused by pancreatic cancer, is very rare. An 86-year-old man was admitted with abdominal pain and fever. The patient denied a history of abdominal surgery, endoscopic retrograde cholangiography, or trauma. Abdominal computed tomography demonstrated a huge collection of fluid in the left lobe of the liver, dilatation of the intra and proximal common bile duct, and a heterogeneous enhancing mass in the pancreatic head portion. Percutaneous drainage under ultrasound guidance was performed, and the fluid analysis was compatible with biloma. A plastic stent was endoscopically inserted into the common bile duct to treat continuous drainage of the fluid despite percutaneous drainage. We report a case of biloma developed spontaneously in a patient with pancreatic cancer and successfully treated by endoscopic biliary stenting.

A Case of Citrobacter braakii Sepsis Complicated with Hepatocellular Carcinoma

Citrobacter species is a gram-negative bacilli that can cause opportunistic infections in immunocompromised hosts. Citrobacter braakii refers to the genomospecies 6 of the Citrobacter freundii complex. There are no detailed studies on infections caused by this newly identified specific genetic species in Korea. We herein report a case of a patient with hepatocellular carcinoma who, after undergoing transcatheter arterial chemoembolization, developed biloma which later progressed to C.braakii sepsis and did not respond to treatment. To our knowledge, this is the first reported case in Korea on C. braakii infection resulting in septic shock in a patient with malignancy in Korea.

Biloma subcapsular hepático y pancreatitis crónica: presentación de caso / Hepatic sub-capsular biloma and chronic pancreatit is: case report

Introducción: El biloma se define como la fuga de bilis intrahepática, extrahepática y a veces retroperitoneal, asintomático o de sintomatología variable, la presencia del biloma subcapsular hepático en un paciente con pancreatitis crónica no ha sido informada en la literatura. Caso clínico: Hombre de 52 años de edad, alcohólico. Se realiza colecistectomía laparoscópica por colecistolitiasis sintomática, reingreso precoz por presentar vómitos, distensión abdominal, ictericia y tumor abdominal doloroso en hemiabdomen superior, el ultrasonograma (US) y la tomografía computarizada (TC) helicoidal abdominal muestran una colección en lóbulo hepático derecho, se realiza drenaje percutáneo (DP), en la colangiopancreatografía retrógrada endoscópica (CPRE) no se observa fuga biliar, anatomía biliar normal, conducto pancreático principal dilatado difusamente con estenosis dispersas. Se realiza esfinterotomía y drenaje. Conclusiones: No existen reportes de la coexistencia entre biloma subcapsular hepático y pancreatitis crónica luego de la colecistectomía laparoscópica, no pensamos que esta sea una relación casual, se exponen factores que justifican la misma.

Background: Bilomas is the intra-hepatic, extra-hepatic and sometimes retroperitoneal collection for bile leak, variable clinic or asymptomatic. However, the clinical association between hepatic sub-capsular bilomas and chronic pancreatitis never has seen to be reports elsewhere in the literature. Clinical case: A 52-year-old alcoholic man who was operated of laparoscopic cholecystectomy for symptomatic cholelithiasis, readmitted for vomiting, abdominal distension, ictericia, abdominal pain tumour in superior abdomen, the ultrasound(US) and helicoidally computer tomography(CT) show the collection in right hepatic lobule, it was evacuated for percutaneous drainage, in endoscopic retrograde cholangiopancreatography(CPRE) no observed bile leak, biliar tree was normal, the main pancreatic duct appeared diffusely dilated with scattered strictures, and finished with endoscopic sphincterotomy and drainage. Conclusions: There are no reports of a clinical association between hepatic sub-capsular bilomas and chronic pancreatitis after laparoscopic cholecystectomy. We believe that there is a physiopathological relationship between then and exposed the facts.

A Case of Infected Biloma due to Spontaneous Intrahepatic Biliary Rupture

A "biloma" is a loculated collection of bile located outside of the biliary tree. It can be caused by traumatic, iatrogenic or spontaneous rupture of the biliary tree. Prior reports have documented an association of biloma with abdominal trauma, surgery and other primary causes, but spontaneous bile leakage has rarely been reported. A spontaneous infected biloma, without any underlying disease, is a very rare finding. We recently diagnosed a spontaneous infected biloma by abdominal computed tomography and sonographically guided percutaneous aspiration. The patient was successfully managed with percutaneous drainage and intravenous antibiotics. We report here a case of infected biloma caused by spontaneous rupture of the intrahepatic duct, and review the relevant medical literature.

A Case of Spontaneous Biloma Complicated with Choledocholithiasis and Chronic Cholecystitis / 대한소화기학회지

A biloma is an encapsulated bile collection outside the biliary tree. Most cases of biloma are caused by iatrogenic injury or trauma. Intrahepatic rupture of the biliary tree due to nontraumatic cause is a rare event. A 68- year-old man was admitted because of abdominal pain and fever. He had no past history of abdominal surgery, instrumentation or trauma. Computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) demonstrated a large subcapsular fluid collection in the right liver associated with choledocholithiasis and cholecystitis. Biloma was confirmed by sono-guided percutaneous needle aspiration and was drained through a pigtail catheter. After the successful treatment by percutaneous drainage and endoscopic sphincterotomy, the patient recovered. Here, we report an uncommon case of spontaneous biloma formation in association with choledocholithiasis with a review of literatures.

A Nontraumatic Rupture of Intrahepatic Bile Duct and Perihepatic Biloma Formation in a Patient with Choledocholithiasis: A Case Report / 한국간담췌외과학회지

A biloma is an extrahepatic or intrahepatic bile collection caused by traumatic, iatrogenic, or spontaneous rupture of the biliary tree. Prior reports have documented an association of a biloma with abdominal trauma and surgery, but spontaneous bile leakage associated with other primary causes has rarely been reported. A 72-year-old man was admitted to our hospital with the complaint of epigastric pain and yellowish discoloration of the sclera. Ultrasonography and computed tomography revealed a large fluid collection in the abdominal cavity. Endoscopic retrograde cholangiography demonstrated leakage of contrast medium from a distended segmental biliary branch in the left lobe of the liver. A perihepatic biloma was confirmed by sonographically guided percutaneous aspiration, and the patient underwent a left lateral segmentectomy of the liver, a cholecystectomy and T-tube choledochostomy. Histological examination showed left lateral bile duct hyperplasia, with abscess formation and chronic cholecystitis. Herein, a case of a biloma associated with choledocholithiasis is reported, with a review of the literatures.

Intrahepatic Biloma after Transcatheter Arterial Chemoembolization: Evaluation of Imaging Findings, Clinical Course and Treatment

PURPOSE: We evaluated the imaging findings, clinical course and treatment of biloma after transcatheter arterial chemoemolization (TACE) of hepatocelluar carcinoma (HCC). MATERIALS AND METHODS: After TACE of HCC in 11 patients with intrahepatic biloma, the findings of dynamic CT and angiography were retrospectively analysed. Hemodynamic change occurring in the hepatic artery and portal vein, the presence of intrahepatic bile duct dilatation, and serum bilirubin levels were analyzed. Changes in the size of the biloma at follow-up study, the extent of additional management, and the overall clinical course were also analyzaed. RESULTS: Hepatic artery obliteration was observed in all cases; this involved the right hepatic artery in eight, and the segmental artery in three. There was decreased portal venous flow in seven cases and portal thrombosis in one. The intrahepatic duct was dilated in all cases but significantly elevated serum bilirubin levels were not noted. Follow-up study showed that in five cases the size of the biloma had increased; in four of these there was infection, and drainage was performed. In the remaining six cases the size of the biloma did not change, even where a segment or lobe had atrophied. CONCLUSION: Angiography showed that after TACE hepatic arterial obliteration occurred in all patients with intrahepatic biloma after TACE. During infection or where a biloma has increased in size, intervention is required.

A Case of Resection of Biloma with Hepatocellular Carcinoma after Embolization / 대한간학회지

Intrahepatic biloma is one of the rare complications occurring after transcatheter arterial chemoembolization (TACE). Biloma after TACE may result from the development of peripheral bile duct necrosis caused by microvascular damage of the peribiliary capillary plexus, and intrahepatic ductal stenosis. We report a case of resection of intrahepatic biloma with hepatocellular carcinoma after TACE.

A Case of Hepatic Biloma Following Endoscopic Retrograde Cholangiography / 대한소화기내시경학회지

Endoscopic retrograde cholangiography has now evolved into a highly sophisticated diagnostic and therapeutic tool in patients with hepatobiliary-pancreatic disorders. However, this procedure is associated with risks of significant complications such as cholangitis, pancreatitis, hemorrhage, and perforation which have been widely recognized. Hepatic subcapsular biloma is a very rare and less recognized complication of this procedure. Recently, we experienced a case of hepatic subcapsular biloma, developed after endoscopic removal of choledocholithiasis, managed with percutaneous drainage procedure and endoscopic stenting, and report with a review of literature.