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Mentions: A 35-year-old Hispanic female underwent a cholecystectomy that began using laparoscopic techniques, but was converted to open cholecystectomy due to bleeding from a small branch of the cystic artery which was easily controlled after laparotomy was performed. An intraoperative cholangiogram was obtained prior to conversion to an open procedure. Common bile duct, cystic duct and cystic artery were in normal anatomic location, and no anatomic abnormalities were identified. The patient was discharged four days after the operation. She returned one week later with complaints of nausea, vomiting, as well as right and left upper quadrant pain. There was no reported change in the color of her stools, urine or skin. Liver function tests showed elevated alkaline phosphatase, AST, ALT, with normal total and conjugated bilirubin. An abdominal ultra-sound study demonstrated large upper abdominal fluid collections bilaterally. Computed tomography (CT) of the abdomen and pelvis showed a large fluid filled structure along the dome of the liver, consistent with a subcapsular fluid collection (Figure 1). There was also marked dilatation of the stomach secondary to kinking of the duodenum by the displaced liver and subcapsular fluid mass. The patient was subsequently hospitalized and placed on naso-gastric suction. Further management included an upper gastrointestinal series that revealed extrinsic compression of the proximal duodenum, creating a partial gastric outlet obstruction (Figure 2). The patient subsequently underwent percutaneous pigtail catheter drainage placed under CT guidance, which spontaneously yielded 1.5 liters of bilious fluid. A hepatobiliary iminodiacetic acid (HIDA) scan obtained one day after the CT guided drainage concluded that there was a bile leak in the region of the gallbladder fossa (Figure 3). Endoscopic retrograde cholangiopancreatography (ERCP) showed that the second portion of the duodenum was normal, with a prominent minor ampulla, and a normal sized bile duct with no apparent leak. The patient had a sphincterotomy performed for decompression, and was subsequently discharged with catheter drainage. Ten days after discharge, the catheter became dislodged and the patient complained of recurrent pain. She was hospitalized and another ERCP was performed. It revealed a leak from a small branch of the right hepatic duct (Figure 4). A catheter drain was replaced and the patient discharged. This leak resolved spontaneously in ten days and the catheter was removed. She has remained asymptomatic and has a normal physical examination on follow-up.
Gastric Outlet Obstruction Secondary to Post Cholecystectomy Biloma: Case Report and Review of the Literature
Bottom Line: There are a number of approaches to the treatment of this uncommon lesion.The literature is reviewed to suggest the optimal management and treatment plans for this complication.This patient was successfully managed with radiologic intervention for the treatment of a biloma and resulting gastric outlet obstruction after open cholecystectomy.
Affiliation: Department of Surgery, Kern Medical Center, Bakersfield, CA 93305, USA.
Background: Postcholecystectomy bilomas are relatively uncommon with a reported incidence of about 2.5%, and most often present with right upper quadrant pain and fever within seven days of the operation. There are a number of approaches to the treatment of this uncommon lesion.
Case report: The authors report a case of a cholecystectomy performed in a 35-year-old female which resulted in a biloma, presenting 11 days postoperatively with gastric outlet obstruction. The literature is reviewed to suggest the optimal management and treatment plans for this complication.
Results: This patient was successfully managed with radiologic intervention for the treatment of a biloma and resulting gastric outlet obstruction after open cholecystectomy.
Conclusion: Although uncommon, bilomas may present in an unusual manner such as with gastric outlet obstruction. As with early bilomas, they may be treated successfully with interventional radiologic techniques.
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