What is the most appropriate management for a post-laparoscopic cholecystectomy patient with a subhepatic biloma and elevated bilirubin levels presenting with vague abdominal pain?

Management of Post-Laparoscopic Cholecystectomy Biloma

Image-guided percutaneous drainage is the most appropriate initial management for this patient with a post-cholecystectomy biloma and elevated bilirubin levels. 1

Rationale for Image-Guided Drainage

The 2020 World Society of Emergency Surgery (WSES) guidelines explicitly recommend that for minor bile duct injuries (Strasberg A-D), if no drain was placed during surgery, percutaneous treatment of the collection with drain placement is the appropriate first step. 1 This patient presents with:

• Confirmed biloma on CT imaging
• Elevated direct and indirect bilirubin indicating ongoing bile leak
• Symptomatic presentation with abdominal pain

Management of biloma requires percutaneous drainage as the primary intervention to achieve source control. 1

Why Not the Other Options?

MRCP (Option A)

• While MRCP can be complementary to CT for exact visualization and classification of bile duct injury 1, this patient already has a confirmed biloma on CT scan
• MRCP would delay definitive treatment when the diagnosis is already established
• The WSES guidelines position MRCP as an adjunct to CT, not a replacement for therapeutic intervention 1

Conservative Management (Option C)

• Conservative observation is only appropriate if a drain was already placed during surgery and bile leak is noted 1
• This patient has no existing drain and has a symptomatic collection requiring intervention
• Without drainage, biloma can progress to abscess or biliary peritonitis 1

Subsequent Management Algorithm

After percutaneous drainage placement:

1. Initiate broad-spectrum antibiotics immediately (within 1 hour) using piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem 1, 2

2. Monitor clinical response over 24-72 hours with serial clinical examination and inflammatory markers 1

3. If no improvement or worsening occurs, proceed to ERCP with biliary sphincterotomy and stent placement, which becomes mandatory at this stage 1, 2

4. Continue antibiotics for 5-7 days for biloma management 1

Critical Pitfalls to Avoid

• Do not delay drainage in symptomatic patients with confirmed biloma - this risks progression to sepsis, abscess formation, or biliary peritonitis 1
• Do not assume the biloma will resolve without intervention - percutaneous drainage is required for source control 1
• Do not withhold antibiotics - patients with biloma require immediate antimicrobial therapy as bile collections are at high risk for infection 1, 2

The elevated bilirubin levels in this patient indicate active bile leakage, making drainage essential for both diagnostic confirmation (fluid analysis) and therapeutic source control. 3, 4