Biloma

A biloma is an encapsulated collection of bile outside the biliary tree.

It usually develops after cholecystectomy, liver resection, liver trauma or another biliary intervention.

A biloma may remain sterile or become infected. Persistent accumulation indicates an ongoing bile leak until proven otherwise.

Small bilomas may be asymptomatic.

Clinically important collections cause:

• Right upper quadrant or general abdominal pain
• Fever
• Nausea
• Abdominal distension
• Persistent postoperative tachycardia
• Sepsis when infected

CT abdomen: defines the collection and provides a route for percutaneous drainage.

MRCP can clarify the biliary source when the anatomy remains uncertain.

Aspiration yielding bile confirms the nature of an uncertain collection and allows culture when infection is suspected.

A small asymptomatic biloma that is no longer enlarging can sometimes be observed.

Drain collections that are:

• Symptomatic
• Large or enlarging
• Infected
• Producing mass effect
• Associated with ongoing postoperative deterioration

Percutaneous catheter drainage is usually first line.

Measure drain output daily.

If bilious output persists, treat the underlying leak rather than leaving the drain indefinitely.

A cystic duct stump or accessory duct leak with preserved bile duct continuity is generally treated with ERCP and temporary transpapillary stenting.

A disconnected or transected major duct requires hepatobiliary reconstruction rather than repeated endoscopic stenting.

Infected biloma requires antibiotics plus drainage. Antibiotics without evacuation of a significant infected collection provide inadequate source control.