Endoscopic drainage of a post-cholecystectomy biloma with biloma–gastric stenting

A 56-year-old woman was admitted with a 2-week history of non-radiating severe upper abdominal pain associated with vomiting. She had developed mild jaundice 1 week prior to admission. She had a history of laparoscopic cholecystectomy 3 months previously with an uneventful postoperative recovery. Her serum bilirubin was 5.9 mg/dL (normal range 0.30 – 1.20), predominantly direct bilirubin, and her alkaline phosphatase was 484 IU/L (normal range 42 – 128). Her blood counts were normal.

Ultrasound and computed tomography (CT) scans of her abdomen were performed, which showed mild dilatation of the central intrahepatic biliary radical and common bile duct (CBD). There was a large cystic collection in the subhepatic space posterior to left lobe of liver ([Fig. 1 a]). On aspiration this was confirmed as being a biloma.

Fig. 1 Computed tomography (CT) scans in a 56-year-old woman with a 2-week history of severe upper abdominal pain and vomiting who had undergone a laparoscopic cholecystectomy 3 months previously showing: a a large biloma in the upper abdomen; b resolution of the biloma 24 hours after insertion of a biloma–gastric stent with specks of air now visible in the biloma.

She underwent an endoscopic retrograde cholangiopancreatography (ERCP) during which biliary sphincterotomy was performed. The cholangiogram showed a 7-mm filling defect in the lower CBD, and Dormia extraction of 7-mm CBD stone was performed. There was no bile leak seen on cholangiogram. In addition, there was a smooth extrinsic compression of the gastric body. The gastric wall over the bulge was punctured with a needle knife and a 0.035-inch guide wire was passed into the biloma. The tract was dilated with a 10-mm controlled radial expansion (CRE) balloon and a 10-Fr, 3-cm double-pigtail stent was placed, which immediately drained bile.

A CT scan repeated 24 hours later showed drainage of the biloma with specks of air now present within it ([Fig. 1 b]). The patient was given intravenous antibiotics for 7 days and remained free of infection.

Endoscopic sphincterotomy and selective stent insertion in conjunction with percutaneous drainage procedures represents, in the majority of cases, the cornerstone of definitive treatment [1]. Endoscopic ultrasound (EUS)-guided drainage and stenting has been reported as an option for the management of postoperative collections [2]. EUS-guided cholangio-drainage (EUCD) has been reported in patients with end-stage biliopancreatic cancer and biliary tract obstruction [3]. The standard of care for biloma has been percutaneous or surgical drainage [4] [5]. Endoscopic drainage of a biloma such as this has not been previously reported in this setting.

Endoscopy_UCTN_Code_TTT_1AR_2AK

Competing interests: None

• References

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