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CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 16 (2015) 7–11

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

journa l h omepage: www.caserepor ts .com

uge biloma after endoscopic retrograde cholangiopancreatographynd endoscopic biliary sphincterotomy

arith M. Alkhateeba,∗, Thaer J. Aljanabib, Khairallh H. Al-azzawic, Taha A. Alkarbolyd

College of Medicine, Tikrit University, IraqCollege of Medicine, Tikrit University, IraqTikrit Teaching Hospital, IraqKurdistan Center for Gastroenterology and Hepatology, Assulaymaniah, Kurdistan, Iraq

r t i c l e i n f o

rticle history:eceived 14 June 2015ccepted 27 August 2015vailable online 1 September 2015

eywords:ilomandoscopic retrogradeholangiopancreatographyphincterotomyercutaneous drainage

a b s t r a c t

BACKGROUND: Biliary leak can occur as a complication of biliary surgery, endoscopic retrograde cholan-giopancreatography manipulations and endoscopic biliary sphincterotomy. Consequently, bile maycollect in the abdominal cavity, a condition called biloma. Rarely, it may reach a massive size.CASE PRESENTATION: A 72-year-old man presented with gastric upset with gradual abdominal disten-sion reaching a large size due to intra-abdominal bile collection (biloma) after endoscopic retrogradecholangiopancreatography plus endoscopic biliary sphincterotomy and stenting for post laparoscopiccholecystectomy common bile duct stricture. This huge biloma was treated by percutaneous insertion ofa tube drain for a few days, evacuating the collection successfully without recurrence.DISCUSSION: This patient might sustain injury to the common bile duct either by the guide wire or stent,or the injury occurred at the angle between the common bile duct and duodenum during sphincterotomy

of the ampulla. Although any of these rents may lead to a bile leak, causing a huge biloma, they could besuccessfully treated by percutaneous drainage.CONCLUSIONS: (1) Following endoscopic retrograde cholangiopancreatography, a patient’s complaintsshould not be ignored. (2) A massive biloma can occur due to such procedures. (3) Conservative treatmentwith minimal invasive technique can prove to be effective.

© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an openhe CC

access article under t

. Introduction

A biloma is defined as an encapsulated collection of bile outsidehe biliary tree. It is mainly caused by iatrogenic injury (surgery,ercutaneous trans-hepatic interventions, endoscopic retrogradeholangiopancreatography “ERCP”) or abdominal trauma involvinghe biliary system; very rarely, it may occur spontaneously [1–3].

Gould and Patel used the term biloma for the first time in 1979o describe a loculated collection outside the biliary tree but hadxtended to include both intra and extra hepatic collections of bile.eaking bile, by virtue of the detergent and tissue destroying actionf bile acids, elicits low-grade inflammation, resulting in a thinapsule or adhesions, thereby forming an isolated collection callediloma [3]. Rarely, it may reach a huge size.

Since its introduction in 1968, ERCP has become a commonlyerformed endoscopic procedure [4]. The diagnostic and therapeu-ic utility of ERCP has been well demonstrated for various disorders,

∗ Corresponding author.E-mail addresses:

hateeb hm@yahoo.com (H.M. Alkhateeb), thaere.jasim@yahoo.com (T.J. Aljanabi),aguar fp@yahoo.com (K.H. Al-azzawi), alkarbolytaha@gmail.com (T.A. Alkarboly).

ttp://dx.doi.org/10.1016/j.ijscr.2015.08.039210-2612/© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Assocreativecommons.org/licenses/by-nc-nd/4.0/).

BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

including the management of choledocholithiasis, the diagnosisand management of biliary and pancreatic neoplasms, and thepostoperative management of biliary perioperative complications[5–7]. The evolution of the role of ERCP has occurred simultane-ously with that of other diagnostic and therapeutic modalities, mostnotably magnetic resonance imaging (MRI)/magnetic resonancecholangiopancreatography (MRCP), laparoscopic cholecystectomy(with or without intraoperative cholangiography), and endoscopicultrasonography (EUS). For endoscopists to accurately assess theclinical appropriateness of ERCP, it is important to have a thoroughunderstanding of the potential complications of this procedure.Numerous studies have helped to determine the expected ratesof complications, potential contributing factors for these adverseevents, and possible methods to improve the safety of ERCP. Therecognition and understanding of potential complications of ERCPare vital in the acquisition of appropriately informed consent [8].Reported complication rates vary widely in the published litera-ture because of differences in study design, patient population, anddefinitions of complications. The diagnosis and management of all

complications of ERCP are beyond the scope of this study.

The most frequent complications of ERCP and endoscopic biliarysphincterotomy (ES) are pancreatitis, cholangitis, haemorrhage,

iates Ltd. This is an open access article under the CC BY-NC-ND license (http://

– OPEN ACCESS8 rnal of Surgery Case Reports 16 (2015) 7–11

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Fig. 1. ERCP showing a post cholecystectomy stricture at the level of the cystic duct.

Fig. 2. Severe abdominal distension 2 months after ERCP, ES and CBD stenting.

CASE REPORT H.M. Alkhateeb et al. / International Jou

BD and duodenal perforation. Several less common adversevents have also been described, including cardiopulmonary com-lications, contrast allergy, impaction of a retrieval basket andumerous other events reported in only small numbers of patientsr individual case reports. These unusual adverse events, whichay be difficult to manage, can be associated with significant mor-

idity and mortality [9,10].Perforation rates with ERCP range from 0.1% to 0.6% [11–15].Three distinct types of perforation have been described: (1)

uidewire-induced perforation, (2) periampullary perforation dur-ng ES, and (3) luminal perforation at a site remote from the papilla16]. Risk factors for perforation determined in a large retrospec-ive study included the performance of ES, Billroth II anatomy,ntramural injection of contrast, prolonged duration of the proce-ure, biliary stricture dilation, and sphincter of Oddi dysfunctionSOD) [14,15]. However, in a more recent multicentre prospec-ive study, only malignancy and precut access were associatedith an increased risk of perforation [14]. Prompt recognition oferiampullary perforation and treatment with aggressive biliarynd duodenal drainage (using nasobiliary and nasogastric tubes)oupled with broad spectrum antibiotics can result in clinical res-lution without the need for operative intervention in as many as6% of patients [17]. The management of perforation will depend onany factors, such as the site and location, clinical status, and radio-

raphic imaging. Early identification and expeditious managementf a perforation have been shown to decrease associated morbid-ty and mortality [18]. Perforations related to endoscopy are bestpproached in collaboration with surgeons [19].

. Case presentation

A 72-year-old man, a diabetic for the last 20 years, underwent difficult laparoscopic cholecystectomy for calculus cholecysti-is with a smooth post-operative period until the 4th monthfter the surgery, when the patient developed an attack of acuteholangitis, upper abdominal pain, a fever of 39.5 ◦C, rigor andild jaundice (total serum bilirubin = 3.5 mg/dl, direct = 2.5 mg/dl,

ndirect = 1 mg/dl), a fasting blood sugar = 162 mg/dl, and a WBCount = 13000/cm m. Ultrasonography (US) revealed mild intrahep-tic biliary tree dilatation with mild CBD dilation of 12-mm calibre,ith a small stone of a 5-mm diameter in its lower part.

With broad-spectrum antibiotic coverage and blood sugar con-rol, the patient underwent ERCP, which showed a dilated intra andxtra hepatic biliary tree with moderate stricture of the CBD at theevel of cystic duct insertion and a small stone in the lower partf the CBD (Fig. 1), ES for the ampulla of Vater and sphincter ofddi done, extraction of the stone was performed using an extrac-

ion balloon, and insertion of a plastic stent in the CBD passing thetricture was performed without the need for CBD dilatation.

The patient improved, and the discomfort, fever, jaundice andeukocytosis disappeared within a few days.

Two weeks later, the patient started to complain of abdomi-al discomfort, epigastric heaviness and fullness, anorexia, nausea,epeated vomiting with gradual abdominal distension, reaching auge size after two months (Fig. 2). Blood investigations and esoph-gogastroduodenoscopy (EGD) were performed and were normal.

US and CT scan examinations revealed a huge fluid collectionith a small amount of gas in between the bowel and anterior

bdominal wall (Figs. 3 and4).Diagnostic aspiration through the abdominal wall using a

yringe revealed a dirty, thick, light-green-coloured fluid, of which

l were aspirated by the syringe, and its direct examination byram staining revealed Gram-negative bacteria with acute andhronic inflammatory cells; the chemical analysis was positive forile pigment and bile salts.

The abdomen remained distended, so we took the patient to theoperating theatre, used five millilitres of local anaesthetic lidocainesolution 2% injected locally just above the umbilicus, and performeda one-centimetre transverse skin incision to introduce a Fr 20 tubedrain into the cavity of the biloma through the anterior abdominalwall fixed by silk suture (Fig. 5). Approximately 11 l of the samefluid was drained (Fig. 6), the abdomen collapsed with no more fluiddischarge after the third day (Fig. 5), the tube drain was removedat the seventh day, and the patient obtained relief from all of hissymptoms, has been doing well and was followed for one year with

no recollection or any other related complaint.

CASE REPORT – OPEN ACCESSH.M. Alkhateeb et al. / International Journal of Surgery Case Reports 16 (2015) 7–11 9

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ig. 3. CT scan of the abdomen in the transverse section showing the large fluidollection.

. Discussion

Although perforation of the biliary system or duodenum is veryare after ERCP, it occurred in this case; however, we could notdentify the exact site of perforation.

Fig. 4. CT scan of the abdomen in the longitudina

Fig. 5. A tube drain fixed to the anterior abdominal wall.

In ES, the cut is usually performed at the angle between theduodenum and CBD at 2 o‘clock. If this cutting is overdone, it mayreach the serosa of the organs that may open to the peritoneal cav-ity. The most probable scenario is that the CBD was injured at thesite of the stricture during insertion of the plastic stent. However,through any of these rents, the bile seeped slowly and gradually intothe Morison pouch enlarging insidiously and heaping in front of theduodenum, transverse colon and greater omentum just behind theanterior abdominal wall, reaching the urinary bladder downward.Because the patient has been diabetic for the last 20 years, he did nothave severe pain due to bile irritation, possibly due to neuropathy,but he was complaining of dyspepsia, epigastric discomfort, andrepeated vomiting due to the pressure effect of the bile collection

on the duodenum and stomach.

Because of the massive collection of bile, we expected a largeperforation; however, it closed spontaneously possibly due to

l section showing the large fluid collection.

CASE REPORT – OPEN ACCESS10 H.M. Alkhateeb et al. / International Journal of Surgery Case Reports 16 (2015) 7–11

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Fig. 6. Some of the am

ecuring the patency of the CBD and bile flow by the insertion ofhe plastic stent in the CBD.

. Conclusion

After ERCP, any complain of the patient should not be ignored,even if it is simple because it may hide a serious underlyingproblem that could be discovered and treated early.

However, very rare, after an ERCP, a biloma can occur that mayreach a very large size causing many symptoms.

The biloma can be treated by aspiration with minimally invasivesurgical interference particularly if the patient is clinically stableand with the help of US guidance.

onflict of interest

The authors declare that they have no competing interests.

unding

No source of funding is needed. The authors are ready to pay theublication fee.

thical approval

It is not needed.

onsents

Written informed consent was obtained from the patient to pub-ish the case with its related pictures. A copy of the written consents available for review by the Editor-in-Chief of this journal.

uthors’ contributions

Harith M. Alkhateeb: Surgery for the patient, writing of the orig-nal text, communication with the editorial team.

Thaer J. Aljanabi: Assistance in the surgery, sharing the analysisf the data, and follow up of the patient.

Khairallah H. Alazzawi: EGD and medical control of the diabetesellitus.

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of the drained fluid.

Taha A. Alkarboly: ERCP, ES of the ampulla of Vater, CBD stoneextraction and plastic stent insertion in the CBD.

Guarantor

Dr. Harith M. Alkhateeb.

Aknowledgments

We would like to thank the patient for allowing us to contacthim for follow up and consenting for us to publish the case withits related photographs. We would like to thank the efficient ultra-sonographist Dr. Bushra M. Shabeeb for her kind help in performingthe follow-up US examinations on the patient. We would like tothank Zayd H. Alkhateeb for his help in the editing of the manuscriptand pictures.

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uted under the IJSCR Supplemental terms and conditions, whichion in any medium, provided the original authors and source are