What is a biloma?

Biloma: Definition, Causes, and Management

A biloma is an encapsulated collection of bile outside the biliary tree, occurring within the abdominal cavity, either intrahepatic or extrahepatic. 1

Definition and Pathophysiology

• Bilomas were initially defined as encapsulated extrahepatic collections of bile, but the definition has expanded to include abnormal intrahepatic bile collections located outside bile ducts 2
• They form as a result of bile leakage from the biliary system, creating a defined capsular space containing bile 1
• Bilomas are considered a type of biliary complication, with an incidence rate of 2.8-30% following certain procedures 3

Common Causes

• Iatrogenic causes are most common, particularly:

  • Laparoscopic cholecystectomy (most frequent cause) 4
  • Hepatobiliary interventions 4
  • Liver transplantation (incidence 10-25% of transplant recipients) 3
  • Liver biopsies 3
  • Hepatic artery thrombosis 3
  • T-tube related complications 3

• Traumatic causes:

  • Blunt or penetrating liver trauma (especially high-grade injuries) 3
  • Abdominal trauma 4

• Other causes:

  • Choledocholithiasis (bile duct stones) 4
  • Biliary strictures 4
  • Spontaneous bile leaks (rare) 4

Clinical Presentation

• Bilomas can be asymptomatic or present with:
  • Fever 3
  • Abdominal pain (particularly right upper quadrant) 3, 4
  • Abdominal distension 3
  • Jaundice (if associated with biliary obstruction) 3
  • Nausea and vomiting 3
  • Signs of sepsis (if infected) 3

Diagnosis

• Laboratory findings:

  • Elevated liver function tests (particularly in obstructive patterns) 3
  • Elevated inflammatory markers (CRP, PCT) if infected 3

• Imaging studies:

  • Abdominal triphasic CT is recommended as first-line imaging to detect fluid collections and ductal dilation 3
  • Ultrasound can identify bilomas but has lower sensitivity than CT 3
  • Magnetic resonance cholangiopancreatography (MRCP) is the gold standard for complete morphological evaluation of the biliary tree 3
  • Contrast-enhanced MRCP provides detailed visualization of biliary anatomy and can detect bile leaks with accuracy close to 100% 3
  • Hepatobiliary scintigraphy can detect active bile leaks but has poor spatial resolution 3

Management

• Most traumatic bilomas regress spontaneously 3
• Symptomatic or infected bilomas require intervention:
  • Percutaneous drainage is the treatment of choice for symptomatic or infected bilomas 3
  • Antibiotics are necessary for infected bilomas 3
  • Combination of percutaneous drainage and endoscopic techniques may be considered for complex cases 3, 5
  • Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement can be used to treat underlying bile leaks 3, 5
  • For complex cases, transpapillary/transfistulary drainage or EUS-guided transmural drainage may be required 5

Complications

• Infection leading to hepatic abscess 3
• Biliary peritonitis if bile leaks into peritoneal cavity 3
• Sepsis if inadequately treated 6

Prevention

• Proper surgical technique during biliary procedures 6
• Early recognition and management of bile leaks 6

Prognosis

• Most bilomas respond well to percutaneous drainage with high success rates and no reported mortality when properly managed 3
• Complex cases may require multiple interventions but can usually avoid additional surgery with appropriate endoscopic management 5