Sclerotherapy as a palliative treatment for spontaneous huge biloma

Abstract

A 91-year-old man with a history of surgically cured nasal cancer and coronary artery disease presented to our emergency department (ED) due to epigastric discomfort and poor appetite lasting for 1 day. He denied any prior trauma, intra-abdominal surgery, or choledocholithiasis. There was no dizziness or exertional dyspnea, but icteric sclera was present. Laboratory testing revealed hyperbilirubinemia (3.67 mg/dl). An abdominal computed tomography (CT scan) showed one huge hepatic cystic lesion with biliary obstruction (Fig. 1a). The surgeon deemed surgical cystectomy or fenestration unsuitable owing to his advanced age and cardiac comorbidity. CT-guided pigtail insertion was done with bile-like fluid aspirated, but no bile duct connection was found. The diagnosis of biloma was favored. After 2 days of drainage, we instilled 70 ml povidone iodine solution into the cyst cavity for sclerotherapy. A non-contrast CT 1 week later showed significant shrinkage of the biloma (Fig. 1b). He was discharged uneventfully after jaundice subsided, with progressive biloma shrinkage during the follow-up months. Bilomas are localized encapsulated pseudotumors consisting of bile juice accumulation, mostly within the hepatic parenchyma and rarely in the peritoneum or abdominal wall [1]. Bilomas result from traumatic injury of intraor extra-hepatic bile duct, or a complication of hepatobiliary procedures (mostly within 6 months). Nontraumatic and non-iatrogenic ones are termed ‘‘spontaneous bilomas’’, as in this patient [2]. Typical presentations are upper abdominal pain, but obstructive jaundice is rather rare, since bilomas commonly harbor connections with bile ducts. The exact mechanism of spontaneous biloma formation is unclear, but spasm of the sphincter of Oddi or biliary diverticuli rupture has been purported as a plausible mechanism [3]. Small bilomas are usually asymptomatic and regress spontaneously within weeks. Large and symptomatic bilomas are often managed with surgical or percutaneous drainage [4]. We have not found any reports concerning sclerotherapy for biloma for those patients unfit for surgery, but it would be a safe alternative option.