Bile Leak After Cholecystectomy

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Introduction: A 59-year-old male with history of hypertension, diabetes and arthritis was admitted with complaints of right upper quadrant abdominal pain, fatigue, jaundice and weight loss of almost 20 lbs. Initial work-up showed a thickened gall bladder on ultrasound and he underwent a cholecystectomy. Three weeks later, the patient presented to the ER with worsening abdominal distension. CT scan of the abdomen showed the patient had a 4.5x3.5 cm pancreatic head mass with large volume ascites concerning for malignant ascites. The tumor was abutting and penetrating into the superior mesenteric vein. Ascitic fluid studies showed an albumin of 1.0 g/dL, WBC -0 k/mm3, and RBC 15,000 k/mm3 and bilirubin of 7.9 mg/dL. Cytology of the peritoneal fluid was negative for malignant cells. Serum albumin was 3.2 g/dL, AST-19 U/L, ALT-27 U/L, alkaline phosphatase-1507 U/L, serum bilirubin-2 mg/dL. Patient was deemed a non-surgical candidate due to the SMV penetration and ascites. EUS was done to take a biopsy of the pancreas and ERCP due to suspected compression of the CBD from the head mass. ERCP showed a biliary stricture and a bile leak from a possible duct of Luschka. (Figure 1) The leak resolved after stenting of the biliary stricture. (Figure 2)Figure 1Figure 2Duct of Luschka or supravesicular ducts are small ducts that originate from the right hepatic lobe and course along the gall bladder fossa to drain directly in the gall bladder or extrahepatic ducts. Post surgical removal of the gall bladder these ducts may remain open and if the CBD gets obstructed due to stones or stricture, it may lead to leakage of bile in the peritoneal cavity due to the back flow. Physicians need to be aware of this complication in the appropriate setting to prevent any delays in starting necessary work-up and treatment.