What is the treatment for a 2x2x4 cm biloma?

From the Guidelines

The treatment for a 2x2x4 cm biloma typically involves percutaneous catheter drainage under ultrasound or CT guidance as the first-line approach. This minimally invasive procedure allows for evacuation of the bile collection while avoiding more extensive surgery. The drainage catheter is usually left in place until output decreases to less than 10-20 mL per day, which may take several days to weeks depending on the underlying cause.

Key Considerations

• Antibiotics such as piperacillin-tazobactam (3.375g IV every 6 hours) or ciprofloxacin (400mg IV twice daily) plus metronidazole (500mg IV every 8 hours) should be administered if infection is present or suspected, as recommended by the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1.
• The underlying cause of bile leakage must also be addressed, which may require endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stent placement to reduce pressure in the biliary system and facilitate healing.
• For bilomas that fail to resolve with drainage alone or recur, surgical intervention may be necessary.

Rationale

This approach is effective because bilomas represent encapsulated collections of bile outside the biliary tree, and drainage both removes the accumulated fluid and creates a tract for continued drainage until the underlying leak seals. The management of biloma and peritonitis requires percutaneous drainage and surgery, respectively, as stated in the 2020 WSES guidelines 1.

Additional Recommendations

• In the case of external biliary fistula without intraperitoneal collection, antimicrobial therapy might not be necessary if infectious signs are absent.
• The optimum duration of antibiotic therapy in the setting of biliary infection is a matter of debate, but according to the Tokyo Guidelines, an additional 4 days of antibiotic therapy is required after source control of cholangitis by decompression of the biliary tree 1.

From the Research

Treatment Options for Biloma

The treatment for a 2x2x4 cm biloma may involve various approaches, including:

• Percutaneous drainage: This method involves inserting a tube drain into the biloma to evacuate the bile collection 2.
• Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and stenting: This procedure can help to relieve the obstruction in the biliary tree and allow the bile to flow freely 3, 4.
• Resection of a liver segment: In some cases, surgical intervention may be necessary to remove the affected liver segment 3.
• Fluoroscopic-guided biloma drainage and ERCP-guided biliary stent placement: This combined approach can help to resolve the symptoms of biloma 4.

Diagnostic Imaging

Diagnostic imaging plays a crucial role in the diagnosis and management of biloma. Various imaging modalities, including:

• Ultrasound
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI)
• Magnetic resonance cholangiopancreatography (MRCP)
• Hepatobiliary iminodiacetic acid (HIDA) scan can help to identify the biloma and guide the treatment approach 4, 5, 6.

Clinical Presentation

The clinical presentation of biloma can be nonspecific, with symptoms such as:

• Abdominal pain
• Nausea and vomiting
• Fever
• Jaundice A high index of clinical suspicion is required for early diagnosis and treatment 4.