What is the management approach for a patient with a biloma?

Management of Biloma

The management of biloma requires immediate source control through percutaneous drainage for symptomatic or infected collections, combined with broad-spectrum antibiotics and endoscopic biliary intervention to address the underlying bile leak. 1

Initial Diagnostic Workup

When biloma is suspected (particularly after hepatobiliary procedures, trauma, or in transplant recipients), obtain:

• Abdominal triphasic CT as first-line imaging to detect fluid collections and ductal dilation 1, 2
• CE-MRCP for complete morphological evaluation of the biliary tree and to identify the leak source 1, 2
• Liver function tests and inflammatory markers to assess severity and guide monitoring 1

Treatment Algorithm

Step 1: Source Control (First Priority)

Percutaneous drainage is the treatment of choice for symptomatic or infected bilomas 1, 2:

• Perform US or CT-guided catheter drainage for all symptomatic collections 1
• For large cholangiolytic abscesses not responding to antibiotics within 48-72 hours, proceed immediately to percutaneous needle aspiration or catheter drainage 1
• Most traumatic bilomas regress spontaneously, but any symptomatic or infected collection requires intervention 2

Step 2: Antibiotic Therapy

Start broad-spectrum antibiotics immediately for infected bilomas or biliary peritonitis 1:

• Recommended regimens: piperacillin/tazobactam, imipenem/cilastatin, or meropenem 1, 3
• Standard duration: 5-7 days for biloma and generalized peritonitis after successful drainage 1, 3
• Extended duration (2 weeks) if Enterococcus or Streptococcus is isolated to prevent infectious endocarditis 1, 3
• Continue parenteral antibiotics for 48-72 hours initially with biliary drainage; if no response, extend to 7-10 days after percutaneous drainage 3

Step 3: Biliary Drainage and Leak Management

Address the underlying bile leak through endoscopic intervention 1, 2:

• ERCP with sphincterotomy is the preferred initial procedure for both diagnosis and treatment 4, 5
• Place biliary stent across the leak site to divert bile flow and promote healing 1, 2, 5
• For recurrent or uncontrolled cholangitis, establish biliary drainage via PTBD or ERCP with stent placement 1
• Remove any retained bile duct stones identified during ERCP 5

Critical pitfall: Failure to perform sphincterotomy in suppurative cholangitis can contribute to bile backflow and worse outcomes 6

Step 4: Complex or Refractory Cases

For bilomas not responding to standard treatment:

• EUS-guided transmural drainage achieves 75% clinical success in complex cases with altered anatomy or conventional treatment failure 7
• Transpapillary/transfistulary drainage with double-pigtail stent placement achieves 67% clinical success 7
• These advanced endoscopic techniques may obviate the need for additional surgery in most patients 7

Step 5: Surgical Intervention

Reserve surgery for:

• Biliary peritonitis requiring source control beyond percutaneous drainage 1
• Major ductal injuries not amenable to endoscopic management 5
• Severe complicated intra-abdominal sepsis with organ failure and gross contamination (consider open abdomen therapy) 1

Special Populations

Liver Transplant Recipients

• Biloma incidence is 10-25% in transplant recipients 2
• Percutaneous or endoscopic stenting of biliary strictures plus biloma drainage may restore normal function 1
• Consider vascular complications; may require stenting or anastomotic revision 1

External Biliary Fistula

• If no intraperitoneal collection exists and infectious signs are absent, antimicrobial therapy may not be necessary 1

Monitoring and Follow-up

• Serial imaging and laboratory tests to monitor treatment response 1
• Regular evaluation of drainage catheters for appropriate removal timing 1
• Monitor for complications including hepatic abscess, biliary peritonitis, and sepsis 2

Common Pitfalls to Avoid

• Do not delay biliary decompression beyond 48 hours in moderate-to-severe cases while continuing antibiotics alone—source control is paramount 3
• Do not continue antibiotics indefinitely for residual anatomical problems; address with repeat intervention 3
• Adjust therapy based on bile and blood culture results once available 3