VA Caribbean Healthcare System San Juan, Puerto Rico
Ricardo López-Valle, MD1, Frances Rodríguez-Berrios, MD1, Hendrick Pagán-Torres, MD2, José Martin-Ortiz, MD1; 1VA Caribbean Healthcare System, San Juan, Puerto Rico; 2VA Caribbean Healthcare System, San Juan
Introduction: Hepatocellular carcinoma (HCC) is a tumor that often occurs in the setting of chronic liver disease. Lesion resection or liver transplant are the preferable management options, however the majority of patients are not eligible for surgery at diagnosis; thus other techniques have to be employed. Trans arterial chemoembolization (TACE) is an alternative often offered to patients with unresectable HCC without vascular invasion or extrahepatic spread. TACE may result in symptoms of abdominal, pain, fever, and transient elevation of liver chemistries. Less commonly, complications include hepatic abscesses, cholecystitis, and injury to the biliary tract. Biliary duct injury, such as a biloma, has been a reported complication in only 0.5 to 2% of cases. There is scarce literature available on alternatives to remedy a subcapsular biloma secondary to TACE. This case exemplifies a novel solution, ERCP as a therapeutic approach to a subcapsular biloma.
Methods: A 82-year-old male with past medical history of HCC underwent second round of TACE. He subsequently presented to the ED with complains of abdominal pain and chills. Abdominal CT performed during evaluation showed an intraabdominal biloma. Interventional radiologist placed percutaneous drainage and biliary fluid from the drainage culture resulted positive for P. agglomerans. Patient improved clinically with antibiotics, however remained with persistent high output via percutaneous drainage. An ERCP was performed with aims to create a biliary diversion by performing a sphincterotomy with stenting of the common bile duct (CBD). The output from percutaneous drainage progressively decreased to less than 10mL/day andt he percutaneous drainage was removed. Biliary stent was also removed approximately 4 weeks later. Discussion: ERCP has been utilized in the past as a successful endoscopic therapy in the treatment of biliary leaks that result from complicated cholecystectomies. Biliary leaks in the form of a biloma is a rare complication of TACE. The objective of sphincterotomy and CBD stent is to eliminate the transpapillary pressure gradient in order to permit biliary flow through a route of least resistance, the intestinal tract.
Image above shows s/p TACE changes with biloma formation
s/p percutaneous drainage
Image shows marked improvement of biloma s/p CBD stent placement as well as percutaneous drainage
Disclosures: Ricardo López-Valle indicated no relevant financial relationships. Frances Rodríguez-Berrios indicated no relevant financial relationships. Hendrick Pagán-Torres indicated no relevant financial relationships. José Martin-Ortiz indicated no relevant financial relationships.