A Case of Post-cholecystectomy Biloma Causing Gastric Outlet Obstruction

Abstract

A biloma is defined as an encapsulated collection of bile outside the biliary tree. It is mainly caused by iatrogenic injury (surgery, percutaneous transhepatic interventions) or abdominal trauma. We report a case of persistent choledocolithiasis in the distal common bile duct (CBD) causing enlargement of a post surgical biloma with subsequent gastric outlet obstruction. The biloma enlargement was due to the persistent bile leak secondary to blockage of the distal CBD. As a result, the bile was trapped, producing a mass effect on the duodenum as visualized during EGD.A 70 year old female with surgical history of cholecystectomy one month prior was admitted for severe abdominal pain, nausea, and anorexia. On admission, her vital signs and exam were normal except for severe RUQ tenderness and distention. CBC and CMP results were evaluated, which revealed a total bili of 0.98, AST 265, ALT 365, and Alk Phos of 1093. Subsequent workup, including CT abdomen/pelvis and ultrasound, showed choledocholithiasis with a stone measuring 3.8 millimeters in the distal common bile duct with proximal ductal dilatation of 8.5 mm and a large fluid filled structure near the gallbladder fossa concerning for biloma. An EGD was performed and showed extrinsic compression of the antrum and proximal duodenum secondary to the biloma resulting in the patients symptoms of gastric outlet obstruction. ERCP was completed and was significant for a leak of contrast from the CBD into the biloma. A sphincterotomy was performed, the ducts were swept, and a biliary stent was placed with a small CBD stone extracted. The patient's liver enzymes improved. On Day 4, a repeat CT abdomen showed improvement of the biloma post stent placement. Repeat EGD revealed resolution of external compression. The patient's symptoms of nausea and vomiting resolved and she was able to tolerate diet.Biloma formation is encountered mainly after surgical or interventional procedures and trauma involving the biliary system. Disruption of the biliary tree after cholecystectomy has been reported in 0-7% of cases. Postcholecystectomy bilomas are rare with a reported incidence of approximately 2.5%, and most often present with RUQ pain and fever within seven days of procedure. There is only one other reported case of biloma post cholecystectomy leading to gastric outlet obstruction, making this a rare complication. Early diagnosis and intervention is crucial to avoid significant morbidity.1276.tif Figure 1: No Caption available.