Idiopathic Benign Impulsive Bilomas

Abstract

"Biloma" is a collection of bile outside of the biliary tree that could occur postoperatively in patients who undergo laparoscopic cholecystectomy or in patients with blunt trauma to the liver. Spontaneous or impulsive bilomas with no identifiable cause occur rarely. We report a case of a 60-year-old woman with no history of hepatobiliary surgery or trauma, who was admitted for right upper quadrant pain. An abdominal examination revealed tenderness in the right upper quadrant (RUQ). Her alkaline phosphatase level was 2,343 IU/L. Computed tomography of the abdomen and pelvis with contrast showed perihepatic, periduodenal, and right paracolic gutter ascites. The image-guided aspiration of the peritoneal cavity yielded greenish fluid that was determined to be bile. The cytological studies were negative for malignancy and microorganisms. The ultrasound images of the RUQ were negative for cholecystitis and gallstones, and the results of the hepatobiliary nuclear scan study (HIDA) were unremarkable. Magnetic resonance cholangiopancreatography (MRCP) revealed an intact intrahepatic and extrahepatic biliary tree and confirmed the presence of multiple lakes of bile ascites. During the entire hospital stay, the patient remained stable without any unifying diagnosis and she was discharged with a pigtail catheter. A follow-up abdominal CT scan revealed a complete resolution of the bilomas. We consider this as a spontaneous extra- and intrahepatic biloma of unknown etiology and should be in our differentials when a patient presents with right upper quadrant abdominal pain.

Keywords: biliary ascites; biloma; cystic duct injury; impulsive biloma; laparoscopic cholecystectomy complication; multiple bilomas; perihepatic ascites; spontaneous bile leak.

Figure 1. Computed tomography scan of the abdomen and pelvis with contrast. The white arrow shows an intact gallbladder without gallstones or evidence of inflammation. The yellow arrow shows fluid from the extrahepatic biloma, tracking along the anterior and lateral hepatic margins.

Figure 2. Computed tomography scan of the abdomen and pelvis with a loculated fluid collection measuring 17.8 × 13.4 × 16.7 cm, which is perihepatic bile ascites that has formed an extrahepatic biloma distorting the hepatic parenchyma.

Figure 3. Magnetic resonance image of the biliary tree showing perihepatic bile ascites causing mass effect on the liver.

Figure 4. Magnetic resonance image of the biliary tree showing an intact intra- and extrahepatic biliary tree without stones or strictures.

Figure 5. Follow-up computed tomography scan of the abdomen and pelvis without contrast shows almost complete resolution of the biloma. The arrow shows a subhepatic pigtail drain.