1322 A Known Complication With a Delayed Presentation: A Rare Case of Biloma Formation Post-Cholecystectomy

Abstract

INTRODUCTION: Biloma is an uncommon complication post cholecystectomy with a reported incidence of approximately 0.3-1.5%. While biloma formation is typically seen within weeks of surgery, there are very few documented cases of biloma formation seen years after an uncomplicated cholecystectomy, as seen in the case below. CASE DESCRIPTION/METHODS: A 35-year-old female with a medical history of cholelithiasis requiring cholecystectomy eight years prior presented with worsening dull right upper quadrant pain with early satiety and abdominal distention for two months. Vitals were stable with her exam notable for a palpable abdominal mass. Labs revealed a mild transaminitis. MRI demonstrated dilated bile ducts and a large 16.1 cm cystic lesion in the gallbladder fossa consistent with a biloma. 1.5 liters of proteinaceous material was drained by interventional radiology. Cultures and cytology were negative for an infectious or malignant process. HIDA scan revealed a bile leak for which she underwent an ERCP where two biliary stents were placed for a segmental duct leak. The patient clinically improved and was discharged home on antibiotics. Two outpatient ERCPs were performed, the first revealing a persistent small leak requiring stent exchange and the subsequent ERCP three months later demonstrating complete closure of the leak. DISCUSSION: A biloma is a demarcated collection localized outside the biliary tree often secondary to iatrogenic, traumatic and even spontaneous injury to the biliary tree. With the introduction of laparoscopic cholecystectomy, incidence of biliary injury has increased from 0.1% to about 0.3-1.5%. The pathophysiology is often secondary to either a leakage of bile from an improper closure of a cystic duct stump, transection of an accessory bile duct or duct of Luschka, or rarely from inadvertent injury of the segmental ducts. Presentation varies and can manifest with abdominal pain, nausea, fever and if large enough can result in obstructive jaundice. Diagnosis is typically 1-2 weeks post-surgery with few cases reported years post-op as seen here. Management is dependent on the size of the biloma and leak. Large bilomas often require percutaneous catheter drainage combined with ERCP with sphincterotomy and biliary stenting whereas small bilomas are treated conservatively. If refractory to endoscopic intervention, surgery may be warranted. We present this case to raise awareness of this uncommon, pathologic entity to help facilitate prompt diagnosis and treatment to avoid poor outcomes.