New Hanover Regional Medical Center Wilmington, NC, United States
Jeremy M. Hess, DO New Hanover Regional Medical Center, Wilmington, NC
Introduction: Post-operative bilomas are an infrequent complication of cholecystectomy, occurring in approximately 0.6-2.2% of cases. They typically present within one week of the initial procedure as right upper quadrant (RUQ) abdominal pain, fever, jaundice, or overt peritonitis.
Case Description/Methods: A 17-year-old male with history of severe obesity, GERD, asthma, and laparoscopic cholecystectomy 5 weeks prior presented to the emergency department with complaints of RUQ abdominal pain ever since his surgery, worsening distention, non-bloody non-bilious vomiting, and constipation with his last bowel movement being 3-4 days ago. Vital signs were BP 140/75, HR 98, Temp 98.3F, RR 24, pulse ox 100% on RA. Physical exam was significant for abdominal distention with diffuse tenderness but no rebound or guarding. Patient was nontoxic in appearance and in no acute distress. WBC 9.3 K/uL without bandemia, AST 28 U/L, ALT 22 U/L, and total bilirubin 0.9 mg/dL. CT abdomen and pelvis with IV contrast was notable for multiple enlarged intra-abdominal fluid collections: the largest within the lower abdomen measuring 29x19x22cm and another 24x13x13cm. The patient was taken for emergent diagnostic laparoscopy which revealed massive intra-abdominal biloma and over 9L of bilious fluid was drained from the abdominal cavity, followed by placement of a 15F right sub-hepatic drain. The next day gastroenterology performed ERCP with sphincterotomy and biliary stent placement which showed bile leak from the cystic duct stump. The drain had >600cc more output overnight, however abruptly stopped and abdominal ultrasound showed persistent residual fluid collections up to 11cm in diameter. Decision was made for removal of drain with close follow-up. Outpatient ERCP in 6 weeks showed no residual biliary leak and patient had gradual resolution of abdominal distention.
Discussion: This case was unusual in its latent presentation 5 weeks after procedure, likely with early development of the biloma being less evident to the patient given his severe obesity. Also unique was the constipation, presumably from mass effect from the sizeable bilomas, and impressive size of the >9L primary fluid collection requiring surgical intervention still with residual bilomas. Also emphasized is the efficacy and importance of therapeutic endoscopy in management of this case, with ERCP both confirming diagnosis and allowing for sphincterotomy and biliary stent placement which prevented re-accumulation.
Jeremy Hess indicated no relevant financial relationships.
Jeremy M. Hess, DO. P1160 - The Bile That Took a While: Latent-Onset Post-Cholecystectomy Massive Biloma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.