Endoscopic ultrasonography‐guided transgastric drainage of infectious biloma following radiofrequency ablation for hepatocellular carcinoma

Abstract

An 87-year-old woman was diagnosed with a 22-mm diameter hepatocellular carcinoma in segment II and treated by percutaneous ultrasound-guided radiofrequency ablation (RFA). Six months later, she presented to the emergency room complaining of high fever and general malaise. Computed tomography (CT) images showed a 96 ¥ 60-mm fluid collection in the left lobe of the liver (Fig. 1). She was diagnosed with sepsis due to biloma infection caused by RFAmediated bile duct disruption. Because the biloma was adjacent to the stomach, we carried out endoscopic ultrasonography (EUS)-guided transgastric drainage of the biloma. A discharge of pus was observed following the creation of internal and external fistulas between the biloma and stomach using a 7-Fr double-pigtail stent and a 7.5-Fr singlepigtail tube (Fig. 2) and cultures of the purulent fluid grew Escherichia coli. A CT scan obtained 4 weeks after drainage confirmed complete resolution of the biloma and the patient recovered uneventfully. Although biloma formation related to bile duct disruption is a frequent complication of RFA, biloma infection complicated with bacteremia is very rare. Bilomas are usually treated by either percutaneous drainage or surgery. This patient, however, was very elderly and had advanced dementia, so it was difficult for her to keep still during percutaneous puncture. In addition, the risk for self-removal of the drainage tube was considered to be high. The utility of EUSguided drainage of intra-abdominal fluid collections is well documented, whereas there have been a small number of reports on EUS-guided drainage of bilomas. The biloma in this patient was located adjacent to the stomach; therefore, EUS-guided drainage was considered to be a promising alternative and was successfully carried out. In summary, the risk of biloma infection should be considered, especially in putative immune-compromised older patients. Moreover, careful attention must be paid to the possibility of delayed biloma infection even 6 months after RFA.