What is the treatment for a biloma?

Treatment of Biloma

The primary treatment for a biloma is percutaneous drainage, which should be performed for symptomatic or infected bilomas, along with appropriate antibiotic therapy if infection is present. 1

Diagnosis and Assessment

• Bilomas should be suspected in patients with fever, abdominal pain, distention, jaundice, nausea, and vomiting, especially following hepatobiliary procedures 2, 1
• Initial diagnostic workup should include:
  • Liver function tests (direct/indirect bilirubin, AST, ALT, ALP, GGT, albumin) 2
  • In critically ill patients, inflammatory markers (CRP, PCT, lactate) help evaluate severity and monitor response 2
  • Abdominal triphasic CT as first-line imaging to detect fluid collections and ductal dilation 2, 1
  • CE-MRCP (contrast-enhanced magnetic resonance cholangiopancreatography) for exact visualization and classification of biliary injury 2, 1

Treatment Algorithm

1. Source Control

• The first priority in bile leakage management is "source control" and early "goal-directed therapy" 2
• Treatment options depend on biloma size, location, and presence of infection:
  • Small, asymptomatic bilomas may regress spontaneously 1
  • Symptomatic or infected bilomas require percutaneous drainage as the treatment of choice 1
  • Large cholangiolytic abscesses not responding to antibiotics within 48-72 hours require US or CT-guided percutaneous needle aspiration or catheter drainage 2

2. Antibiotic Therapy

• For infected bilomas or biliary peritonitis, start broad-spectrum antibiotics immediately (within 1 hour) in cases of sepsis or shock 2
• Recommended antibiotics include:
  • Piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam 2
  • Add amikacin in cases of associated shock 2
  • Consider fluconazole in fragile patients or cases of delayed diagnosis 2
• Duration of antibiotic therapy:
  • For biloma and generalized peritonitis, treatment of 5-7 days is recommended 2
  • Continue antibiotics for 2 weeks if Enterococcus or Streptococcus is present 2

3. Biliary Drainage

• For recurrent or uncontrolled cholangitis, biliary drainage should be established 2
• Options include:
  • Percutaneous transhepatic biliary drainage (PTBD) 2, 1
  • Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement to treat underlying bile leaks 1, 3

4. Management of Complications

• For biliary peritonitis: surgical intervention may be required in addition to percutaneous drainage 2
• For severe complicated intra-abdominal sepsis: open abdomen therapy may be considered for optimal source control in patients with organ failure and gross contamination 2
• For vascular complications associated with bilomas (hepatic artery thrombosis): consider vascular stenting or anastomotic revision 2

Special Considerations

• In liver transplant recipients with bilomas:
  • Percutaneous or endoscopic stenting of biliary strictures and drainage of bilomas may restore normal function 2
  • However, retransplantation is frequently required in severe cases 2
• In cases of external biliary fistula without intraperitoneal collection, antimicrobial therapy might not be necessary if infectious signs are absent 2

Monitoring and Follow-up

• Monitor response to treatment with serial imaging and laboratory tests 2
• For patients with biliary drainage catheters, regular evaluation for appropriate removal timing is necessary 1
• Complete resolution of biloma should be confirmed before removing drainage catheters 4