1382 A Case of Candidal Infection of Large Biloma After CT-Guided Liver Biopsy

Abstract

INTRODUCTION: Bilomas are collections of bile, either intra- or extrahepatic, with or without a capsule. They typically occur due to disruptions or injuries within the biliary. Complications include peritonitis and sepsis due to secondary infections. Clinical symptoms range from abdominal fullness, dull right upper quadrant pain to nausea, vomiting, and fever. Therapy includes drainage and if persistent, then possibly even surgery. This case describes an atypical presentation of a biloma infected with an uncommon pathogen. CASE DESCRIPTION/METHODS: A 64-year-old male with a medical history of alcohol abuse and CT-guided liver biopsy 7 days prior (confirming autoimmune hepatitis) presented to the ED with lethargy, dizziness, anorexia and intermittent diffuse abdominal pain. A CT on admission showed multiple lobulated cystic lesions in the right hepatic lobe communicating with the intrahepatic biliary ducts indicating bilomas. Zosyn was started empirically given his symptoms and leukocytosis. An ERCP was performed, demonstrating a large biloma in segment seven and eight. A 7 Fr × 12 cm stent was placed and the biloma was drained. Culture of the biloma fluid showed candida and numerous neutrophils, prompting the addition of fluconazole. An ERCP was repeated to replace the previous stent with a 10 Fr × 12 cm stent. The patient finished his course of antibiotics and antifungals and signed out against medical advice. He was lost to follow up at our hospital. DISCUSSION: Bilomas, while relatively rare, mainly occur due to disruptions of the biliary tree from laparoscopic cholecystectomies, Billroth II procedures, blunt abdominal trauma, radiofrequency ablation or in our case, a liver biopsy. Complications include peritonitis and sepsis as well as secondary infections with gram-negative bacteria. While our patient's biloma was infected, he had a candidal infection, making his case even more unusual. The gold standards for diagnosis are either hepatobiliary cholescintigraphy with Tc-99m-iminodiacetic acid chelate complex as a tracer or an ERCP which can simultaneously identify and treat bilomas. Treatment involves drainage, either endoscopically or percutaneously. The approach is dependent on the patient's clinical status and if he or she can tolerate an endoscopy. Post-procedure imaging is necessary to confirm drainage of the biloma. If it persists, then further drainage or surgical resection of the biloma are options once the patient is no longer septic.