P2145 - Endoscopic Management of Bile Leak and Associated Biloma Incurred After Ballistic Wound

Michael Coles, MD¹, Rohan Mundkur, BSc¹, John Erikson Yap, MD^2
1Medical College of Georgia, Augusta, GA; ²Medical College of Georgia at Augusta University, Augusta, GA

Introduction: A biloma is an encapsulated collection of extravasated bile beyond the hepatobiliary system. Although rare, bilomas are associated with mortality rates from 11-16% necessitating expeditious recognition and management. Bilomas should be included on the differential diagnosis in patients with abdominal pain and/or constitutional symptoms in the setting of recent intra-abdominal instrumentation or trauma.

Case Description/Methods: A 16-year-old male was admitted in hemorrhagic shock after a gunshot wound to the right thoracoabdominal area with ballistic injury of the 2nd and 3rd portions of the duodenum, IVC, IV/V liver segments and gallbladder wall. The patient underwent exploratory laparotomy with cholecystectomy, IVC repair with omental patch and partial small bowel resection with primary anastomosis. Post-operatively, the patient developed acute abdominal pain, fever to 38.2 C and leukocytosis to 22mm3 with unremarkable labs otherwise. Computed Tomography of the abdomen with IV contrast (Fig. 1A) revealed a 7.1 x 5.5 cm fluid and gas collection within the gallbladder fossa concerning for an enlarging biloma. A follow up hepatobiliary iminodiacetic acid scan (Figure 1B) noted a right hepatic duct leak. A CT guided percutaneous drain was placed to prevent further bile accumulation. ERCP was then performed and a 10 Fr x 9 cm stent was placed in the right hepatic duct. With effective source control and concurrent broad-spectrum antibiotics, the patient defervesced and was ultimately discharged in stable condition.

Discussion: Compromised hepatobiliary endoluminal integrity can lead to bile translocation, accumulation and microbial proliferation within the abdomen. Presenting symptomatology and lab indices are often non-specific and if overlooked can result in biliary peritonitis, cholangitis, and sepsis. The optimal management algorithm is controversial as both endoscopic and surgical modalities are effective with no large prospective comparative controlled trials completed. In the early post-operative phase, the local inflammatory response associated with surgical repair favors endoscopic treatment. As such, endoscopic therapy was utilized to eliminate the transpapillary pressure gradient, through sphincterotomy and stent placement; effectively permitting preferential transpapillary bile flow and reducing hydrostatic pressure at the site of the leak. Initial endoscopic intervention does not preclude subsequent surgical intervention if complications arise but the converse is not always true.


Figure: 1A: Computed Tomography with contrast of the abdomen in the axial view demonstrating a 54.9mm x 71.1mm collection of bile fluid and gas, with dimensions demarcated by red lines.

1B: A Hepatobiliary Iminodiacetic Acid Scan demonstrating bile leak/biloma in the gallbladder fossa with no free intraperitoneal tracer.


Disclosures:
Michael Coles indicated no relevant financial relationships.
Rohan Mundkur indicated no relevant financial relationships.
John Erikson Yap indicated no relevant financial relationships.


Michael Coles, MD¹, Rohan Mundkur, BSc¹, John Erikson Yap, MD². P2145 - Endoscopic Management of Bile Leak and Associated Biloma Incurred After Ballistic Wound, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.