What is the best management approach for an adult patient with a suspected biloma, likely due to a history of liver disease or recent abdominal surgery?

Biloma Management

Initial Management Strategy

For an adult patient with suspected biloma, the optimal management approach is CT-guided or ultrasound-guided percutaneous catheter drainage as the first-line intervention, followed by ERCP with biliary sphincterotomy and stent placement if drainage alone fails to resolve the bile leak. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis and assess severity:

• Obtain abdominal triphasic CT as first-line imaging to detect the fluid collection, assess its size and location, and identify ductal dilation 3, 4
• Add contrast-enhanced MRCP for exact visualization and classification of any bile duct injury, particularly to identify the leak source and assess biliary anatomy 3, 4
• Assess liver function tests including direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin to evaluate the severity of biliary obstruction 3, 4
• In critically ill patients, add CRP, procalcitonin, and lactate to evaluate for sepsis 3, 4

Ultrasound is useful for initial assessment and can identify bile leaks in grade IV-V liver injuries, but CT provides superior anatomical detail for treatment planning 3. MRCP represents the gold standard for complete morphological evaluation of the biliary tree with sensitivity of 76-82% and specificity of 100% 1.

Step-by-Step Management Algorithm

Immediate Management (First 24-48 Hours)

• Perform CT-guided or ultrasound-guided percutaneous catheter drainage of the biloma collection to achieve source control and prevent progression to sepsis or biliary peritonitis 1, 2
• Initiate broad-spectrum antibiotics immediately (within 1 hour) using piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem for patients with biloma, biliary fistula, or bile peritonitis 3, 2, 4
• Continue antibiotics for 5-7 days for biloma management 2

Both CT-scan and ultrasound-guided drainage are equally effective for managing perihepatic fluid collections 3. The World Society of Emergency Surgery guidelines specifically recommend percutaneous treatment with drain placement as the appropriate first step for minor bile duct injuries when no drain was placed during surgery 1, 2.

Monitoring Phase (24-72 Hours)

• Monitor clinical response with serial clinical examination and inflammatory markers to assess treatment effectiveness 2
• Assess drain output characteristics (volume, color, bilirubin content) to determine if the bile leak is resolving
• Repeat imaging if no clinical improvement to evaluate for complications such as abscess formation or ongoing leak 3

Definitive Management (If Drainage Alone Fails)

• Proceed to ERCP with biliary sphincterotomy and stent placement if no improvement or worsening occurs during observation, which becomes mandatory at this stage 1, 2, 4
• ERCP reduces the transpapillary pressure gradient, allowing preferential bile flow through the papilla rather than the leak site, with success rates of 87.1-100% depending on leak grade and location 1
• Use plastic stents as first-line therapy for bile duct leaks 1
• For refractory leaks, fully covered self-expanding metal stents are superior to multiple plastic stents 1

ERCP is particularly effective for cystic duct stump leaks and peripheral bile duct injuries (Strasberg Type A), though it has limitations in visualizing aberrant or sectioned bile ducts and proximal intrahepatic leaks 1, 4.

Context-Specific Considerations

Post-Surgical Biloma (Cholecystectomy)

• Minor bile duct injuries (Strasberg A-D) including cystic duct stump leaks can be managed with percutaneous drainage followed by ERCP if needed 1, 2
• Major bile duct injuries (Strasberg E1-E2) involving transection of the common hepatic or common bile duct require urgent referral to an HPB center for surgical repair with Roux-en-Y hepaticojejunostomy 1, 4

Trauma-Related Biloma

• Biliary complications occur in 30% of cases following blunt hepatic trauma, particularly after high-grade injury 3
• Ultrasound is useful for assessment of bile leak/biloma in grade IV-V injuries, especially with central laceration 3
• ERCP with stenting is effective for managing bile duct injuries resulting from liver trauma 3

Liver Disease-Related Biloma

• In patients with underlying liver disease, the same management algorithm applies, but consider the increased risk of complications from coagulopathy
• Ensure correction of coagulopathy before percutaneous drainage procedures

Critical Pitfalls to Avoid

• Do not delay drainage of large collections (>5 cm) as they are at high risk for infection and sepsis 1
• Do not assume the biloma will resolve without intervention - percutaneous drainage is required for source control 2
• Do not proceed directly to surgery without attempting minimally invasive approaches first, as surgical drainage carries significantly higher morbidity and mortality 1
• Do not rely on ultrasound monitoring alone as it cannot address the underlying bile leak mechanism, and additional interventions such as ERCP may be necessary 1
• Do not withhold antibiotics in patients with biloma, as they require immediate antimicrobial therapy 2
• Normal ERCP findings don't exclude biliary injury - Type A injuries show normal main biliary anatomy despite active leakage 1

When to Escalate to Surgery

• Surgical intervention (open or laparoscopic) is reserved for:
  • Major bile duct injuries (Strasberg E1-E2) 1, 4
  • Failure of endoscopic management 3
  • Presence of necrosis and devascularization of hepatic segments 3
  • Diffuse biliary peritonitis requiring urgent abdominal cavity lavage and drainage 1

The combined approach of percutaneous drainage and ERCP-guided biliary stenting has been shown to result in complete resolution of symptoms in case reports 5, supporting this stepwise algorithm.