A 74-year-old woman presented with upper abdominal pain. An ultrasound scan showed
signs of acute cholecystitis but the liver parenchyma and liver function tests were
normal. She underwent laparoscopic cholecystectomy. An intraoperative cholangiogram
was normal.
On the 12th postoperative day, she presented to the emergency room with right upper
quadrant pain. She had an elevated white blood cell count (13.2 × 109/L [upper limit of normal 8 × 109/L]) and C-reactive protein (30 mg/L [upper limit of normal 5 mg/L]). Her liver function
tests remained normal. An abdominal computed tomography (CT) scan revealed a hepatic
subcapsular fluid collection ([Fig. 1]). This was drained percutaneously and was shown to be a biloma. A drainage catheter
was left in place.
Fig. 1 Computed tomography scan performed 12 days following laparoscopic cholecystectomy
showing a large hepatic subcapsular collection but no other abnormality.
Three days later, ≥ 500 mL of bile continued to drain daily and an endoscopic retrograde
cholangiopancreatography (ERCP) was performed. A cholangiogram showed a bile leak
from the cystic duct stump communicating with the hepatic subcapsular space ([Fig. 2]). An endoscopic sphincterotomy was performed and a biliary stent was inserted.
Fig. 2 Endoscopic retrograde occlusion cholangiogram showing a bile leak from the cystic
duct stump communicating with the hepatic subcapsular biloma. The percutaneous drainage
catheter can be seen in the upper left side of the image.
The percutaneous drainage catheter was removed 2 days post-ERCP. The patient had an
uneventful recovery, and 4 weeks later repeat CT scan showed complete biloma regression.
Repeat cholangiogram upon stent removal 4 months later showed no bile leak.
Although bile leak into the peritoneal cavity is a well-known complication of laparoscopic
cholecystectomy, subcapsular bilomas only rarely occur [1]
[2]
[3]
[4]
[5]. A case of subcapsular biloma has been reported following iatrogenic common bile
duct transection [2], but usually no bile leak site is identified [1]
[3]
[4]
[5]. However, in most published reports, ERCP was not performed [3]
[4]
[5], and subcapsular bilomas were treated with percutaneous drainage [1]
[3]
[4]
[5].
To our knowledge, the current case is the first in which a bile leak from the cystic
duct stump has been shown to be the cause of hepatic subcapsular biloma. It also indicates
that ERCP with biliary stenting is a valid treatment in patients with hepatic subcapsular
bilomas following cholecystectomy.
Endoscopy_UCTN_Code_CPL_1AM_2AF
