Endoscopic Management of Biliary Leak After Liver Biopsy

Abstract

Introduction: Percutaneous liver biopsies are considered quite safe with a rate of fatal complications <1/1000. Biliary leak with biliary peritonitis is a rare (0.03-0.22%) but known complication of percutaneous liver biopsy. Larger extra hepatic duct injury with this procedure is extremely rare. It may present as frank peritonitis with systemic response, hence the likely hood of it responding to conservative management is less. HIDA scan is diagnostic. ERCP along with sphinctrotomy and stent placement in common bile duct is the procedure of choice. We report a case of common hepatic duct injury after CT guided liver biopsy which to the best of our knowledge has not been reported in literature. Case: A 46-year-old lady with a history of autoimmune hepatitis presented with epigastric pain radiating to right flank, associate with nausea and vomiting. A CT guided liver biopsy was done 5 days before presentation. On examination she had pulse of 100/min, BP 94/53 & temperature 99.2 F. Abdomen was tender all over with guarding in the right upper quadrant and hypoactive bowel sounds. Initial labs showed total WBC of 10.6, total bilirubin 2.4 mg/dl and direct bilirubin 1.0 mg/dl. CT scan abdomen revealed fluid surrounding the liver and HIDA scan showed extra hepatic biliary leak. She was initially managed conservatively with nothing by mouth, intravenous fluids, pain medications and antibiotics; however her condition did not improve in 48 hours. ERCP (endoscopic retrograde cholangio pancreatography) was done which showed high-grade biliary leak at the common hepatic duct. A CBD stent was placed. Patient's clinical condition improved significantly after the therapeutic ERCP and was subsequently discharged home. One week follow-up HIDA scan revealed no extra hepatic biliary leak. Six weeks later, stent was removed via ERCP and repeat cholangiogram did not demonstrate any contrast extravasation. Conclusion: In conclusion, extra hepatic biliary duct injury is an extremely rare but potentially life threatening complication of liver biopsy. One should consider it in the differential diagnosis of abdominal pain after liver biopsy as prompt endoscopic treatment can be lifesaving.Figure A: Endoscopic Cholangiogram showing high grade biliary leak at the level of common hepatic (arrow). Figure B. Endoscopic Cholangiogram 6 weeks later showing no leak.