What is the treatment for bile peritonitis?

Treatment of Bile Peritonitis

For patients with diffuse biliary peritonitis, urgent abdominal cavity lavage and drainage are required as the first step of treatment to achieve infection source control. 1

Initial Management

• Prompt source control is the first priority in bile peritonitis and should be accompanied by early "goal-directed therapy" 1
• Broad-spectrum antibiotics should be started immediately (within 1 hour) in the presence of severe sepsis or shock 1
• Recommended antibiotics include piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam; amikacin should be added in cases of associated shock, and fluconazole in cases of frailty or delayed diagnosis 1

Management Based on Type of Bile Duct Injury (BDI)

Minor BDIs (Strasberg A-D)

• If a drain was placed during surgery and bile leak is noted, an initial observation period with non-operative management is appropriate 1
• If no drain was placed during surgery, percutaneous treatment with drain placement should be performed 1
• If symptoms worsen or do not improve after percutaneous drainage, endoscopic management becomes mandatory, including ERCP with biliary sphincterotomy and stent placement 1

Major BDIs with Diffuse Peritonitis

• Urgent abdominal cavity lavage and drainage are essential for infection source control 1
• For major BDIs diagnosed within 72 hours, referral to a center with hepatopancreatobiliary (HPB) expertise is recommended if not locally available 1
• Urgent surgical repair with bilioenteric anastomosis (Roux-en-Y hepaticojejunostomy) may be performed in these early cases 1, 2

Major BDIs Diagnosed Between 72 Hours and 3 Weeks

• Percutaneous drainage of fluid collections is recommended 1
• Targeted antibiotic therapy and nutritional support should be provided 1
• ERCP with sphincterotomy (with or without stent) can be considered to reduce pressure gradient in the biliary tree 1

Endoscopic Management

• ERCP is a key tool in BDI management as it allows identification of the leak site and internal biliary drainage 1
• Success rates of ERCP range between 87.1% and 100%, depending on the grade and location of the leak 1
• Endoscopic treatment is most effective for leaks located at the cystic duct stump or from a duct of Luschka 1
• The main goal is to reduce transpapillary pressure gradient to facilitate preferential bile flow through the papilla rather than the leak site 1

Percutaneous and Surgical Options

• Percutaneous biliary drainage (PTBD) should be reserved for cases where ERCP fails 1
• PTBD can lead to complications including biliary peritonitis, hemobilia, pneumothorax, hematoma, and liver abscesses 1
• Open drainage should only be used when endoscopic or percutaneous drainage is contraindicated or unsuccessful 1
• In cases of post-operative localized intra-abdominal abscesses without generalized peritonitis, antibiotics and/or percutaneous drainage may be sufficient 1

Antibiotic Duration

• For biloma and generalized peritonitis, antibiotic treatment of 5-7 days is recommended 1
• According to Tokyo Guidelines, an additional 4 days of antibiotic therapy is required after source control of cholangitis by decompression of the biliary tree 1
• Treatment should be extended to 2 weeks if Enterococcus or Streptococcus is present to prevent infectious endocarditis 1
• Some studies suggest that only 3 additional days of antibiotics after source control are sufficient to reduce recurrence risk 1

Special Considerations

• In cases of external biliary fistula without intraperitoneal collection, antimicrobial therapy might not be necessary if infectious signs are absent 1
• For complex BDIs requiring delayed surgical repair, complete healing of the fistula is an absolute prerequisite for surgery 1
• Laparoscopic evacuation and lavage may be considered for large bile collections not amenable to percutaneous drainage, particularly in patients with systemic inflammatory response syndrome or respiratory compromise 3