What is Hepatic Biloma?
In 1979, Gould and Patel introduced the term “biloma” to describe a contained collection of bile outside the liver due to bile leaking into the cavity surrounding internal organ space, known as the peritoneal cavity. But as time went on, “biloma” has become a term to describe any clearly defined collection of bile within the abdomen but outside the bile transport system.
A biloma can form inside or outside the liver due to a disruption of the bile transport system. Currently, a biloma doesn’t have to be encapsulated or contained, even if many are. The clear boundaries of a biloma separate it from ongoing bile leaks or freely flowing bile within the peritoneal cavity. Other terms for free bile in the peritoneal cavity are “choleperitoneum” and “bile ascites,” though they’re sometimes used interchangeably with “biloma.”
The most common causes for a biloma are medical procedures or abdominal injuries that lead to damage to the bile transport system, causing a bile leak. Although not common, bilomas may lead to infections, ongoing bile leaks, and put pressure on nearby structures. They may also cause significant health issues and even be life-threatening if not detected and managed appropriately.
Medical imaging tools like ultrasound, CT scans, MRI, or scans of the liver and bile transport system can be used to diagnose a biloma. This information helps the medical team plan a minimally invasive treatment where possible.
What Causes Hepatic Biloma?
Bilomas, or abnormal build-up of bile outside the bile ducts in your liver, can often be a result of damage to your bile-transporting system. This damage could be caused by several things such as doctor-led procedures like gallbladder removal or liver transplant, or on occasion, physical injury.
The number of people developing bilomas has increased as a result of the growing use of a procedure called laparoscopic cholecystectomy (keyhole gallbladder removal) over the last thirty years. This procedure leads to injuries to the bile ducts, the paths that carry bile, in about 0.6 to 1.5% of cases compared to about 0.2 to 0.3% with open operations. Bile leaks after this procedure could be due to damage to the main bile duct, a failed attempt to tie off the duct leading to the gallbladder, or unexpected anatomical changes that result in harmed or leaking secondary ducts. Notably, small ducts called the ducts of Luschka, which are prevalent in about 25 to 35% of patients, can be damaged during this procedure. Fluid build-up, including bile leakage, is more common after gallbladder removal than many doctors may realize, although many of these cases resolve on their own without needing additional treatment.
Similarly, perforation, or hole formation in the common bile duct, following an ERCP (a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas) can also lead to bilomas. Additionally, bilomas have been found in 3.3% of patients who had radiofrequency ablation, a procedure used to treat liver cancer, albeit being classified as a minor complication in this context.
Bilomas can also develop as a result of Transcatheter Arterial Chemoembolization (TACE), a procedure for liver cancer treatment. This was found to have occurred in about 1.04% of a tested patient group. Liver transplant is another common cause of bilomas, as it often leads to post-transplant cholangiopathies (liver diseases related to the bile ducts). The development of these diseases after a transplant may involve various factors such as injury caused by interrupted blood supply, bile salt toxicity, or immune-related injury.
Apart from medical procedures, physical trauma to the abdomen can also lead to biloma formation. Bilomas can also occur spontaneously although very rarely, often due to underlying weaknesses in the walls of the bile ducts caused by conditions like gallstones, liver abscess, or tuberculosis infection. People with sickle cell disease can develop bilomas too, likely because of liver damage. Bile leakage without damage to the bile-transporting system, as is found following Billroth II surgery (a stomach operation), can also lead to biloma formation.
Risk Factors and Frequency for Hepatic Biloma
Biloma formation is a condition that we don’t know much about in terms of how often it happens. Mostly, bilomas form due to procedures that disrupt the natural functioning of the bile ducts. So, the number of biloma cases really depends on how often these procedures are conducted. Usually, it’s people aged 60 to 70 who get bilomas. This is likely because they need more surgical interventions rather than them being more prone to developing bilomas. Both men and women get bilomas equally often.
The formation of bilomas naturally, without the influence of any medical procedures, is very rare. So rare, indeed, that only individual case studies are available in this area. In a specific 2007 study by Ahktar and colleagues, the authors found that since 1979, only 27 cases of spontaneous biloma, or biloma that wasn’t caused by surgical interventions, had been reported.
Signs and Symptoms of Hepatic Biloma
Bilomas are a health issue that often result from damage to the bile ducts caused by medical procedures or accidents. Typical signs are a feeling of fullness in the upper abdomen, discomfort on the right side of the upper abdomen, nausea, vomiting, and occasionally fever. It is particularly important to note any recent surgeries in the stomach area, on the gallbladder, or any abdominal accidents as these increase the chance of developing bilomas.
Some individuals might not show any symptoms at all, while others can become severely ill. Symptoms can vary greatly, making biloma diagnosis challenging. Complications can occur such as “bile peritonitis”, where bile leaks into the abdomen causing inflammation – although this is an uncommon scenario. Interestingly, a study found that significant pain and abdominal tenderness were only present in 21% of patients who developed bilomas after gall bladder surgery. Even though it’s a lesser known condition, any delay in recovery from gallbladder or liver surgeries could be signs of a biloma formation.
Physicians need to stay alert to persistent signs like bloating, lack of appetite, or prolonged abdomen swelling. This condition should always be considered when diagnosing patients with upper abdominal discomfort, especially after surgeries or procedures in the biliary tree region, even if the symptoms are subtle, due to the potential severe consequences.
Testing for Hepatic Biloma
If you have a biloma, a type of cyst in the bile ducts of your liver, your doctor might want to run some tests. Blood tests can show increased levels of white blood cells (leukocytosis), a particular type of white blood cell (neutrophilia), and a protein called C-reactive protein (CRP). These signs can show that your body is fighting an infection or reacting to inflammation. However, not all people with bilomas will have abnormal test results—some studies have found normal blood results in nearly half of patients with bilomas.
If the biloma is impacting your bile duct, your liver function tests might show abnormal results. If the biloma is infected, a blood culture test might find bacteria in your blood. Many bilomas have been found to contain bacteria like Enterobacteriaceae, which might be resistant to multiple types of drugs.
Because bilomas might not always cause obvious symptoms, imaging tests are usually needed to make a diagnosis. These tests might include ultrasound, CT scans, MR imaging, and HIDA scans.
Ultrasound, often the first test because many patients experience discomfort in the right upper quadrant of the abdomen, can usually identify a biloma as a cyst-like lesion. It might also show signs of debris or blood clots within the biloma. Infected bilomas might look like they have many small pockets or compartments—these are called “loculated” bilomas.
CT scans might show a biloma as a well-defined mass with clear borders, but not always. The biloma might look less dense than normal liver tissue. However, a CT scan can’t definitively identify a biloma—it might look like other conditions that could cause a similar mass, so additional tests might be needed.
MR imaging can provide more information about the characteristics of the biloma. For example, a biloma might look like it has a low brightness (or intensity) on T1-weighted images and high intensity on T2-weighted images. Sometimes, contrast dye can help point out inflammation around the biloma. This type of imaging might also show the source of any bile leaks.
HIDA scans can also help diagnose a biloma. These scans use a radioactive dye (Tc-99m iminodiacetic acid) to track the flow of bile from your liver to your small intestines. While this test can be very helpful in finding a bile leak, it might not provide a detailed image of the surrounding tissues and organs. Single positron emission computed tomography (SPECT) can provide a more detailed image and can be useful in planning for any necessary image-guided drains.
If imaging and other tests aren’t clear, your doctor might need to take a sample of the biloma using ultrasound or CT guidance. This sample can then be analyzed in a lab to confirm the diagnosis.
Treatment Options for Hepatic Biloma
The treatment of a biloma, a buildup of bile outside the biliary system, depends on the symptoms, laboratory results, and imaging findings. There are three general methods of treatment: drainage either through a skin puncture or using specialized instruments passed through the digestive tract, surgical drainage, or simply watching and waiting. The choice of treatment will depend on whether or not there’s ongoing leakage of bile, the size and location of the biloma, whether an infection has set in, and the overall health status of the patient.
If the biloma is small and causing no symptoms, it may be absorbed by the body without any need for intervention. However, it’s been shown that bilomas larger than about an inch and a half don’t tend to go away on their own, and it’s hard to predict if they will cause symptoms in the future.
The majority of bilomas can be successfully treated with a procedure called percutaneous drainage, a technique involving use of a needle to remove fluid, which is guided by imaging techniques. This is typically performed by an interventional radiologist, a doctor who specializes in minimally invasive techniques. They may use either ultrasound (US) or computed tomography (CT) scanning to guide the needle’s placement. Ultrasound is often preferred due to its lack of radiation and ability to provide real-time images. To avoid damaging blood vessels, the radiologist uses color and Doppler techniques. If the biloma is difficult to reach, it might need to be accessed via the liver. Other drainage methods can be done with endoscopic ultrasound, a procedure that uses sound waves to produce images and guide treatments.
If the bile continues to leak, further treatments might be needed. This could mean surgery or placement of a stent, which is a tube used to keep a passageway open. It’s often recommended to drain the biloma first in patients who are not feeling well or have symptoms, especially after gallbladder removal surgery. In some cases, it may be necessary to perform other types of drainage procedures to further assess the bile ducts or relieve pressure in the gallbladder when there’s an ongoing bile leak.
Surgery to manage a biloma might be necessary if percutaneous drainage didn’t work, the biloma has many compartments, or there’s ongoing bile leakage. Cases of bile leaks found during gallbladder removal surgery or needing surgical management for ongoing bile leaks are best handled in specialized tertiary centers, facilities that are equipped to handle complex cases.
Bilomas are rare, which means there’s limited evidence informing the best treatment methods. However, percutaneous drainage has been shown to be a successful treatment method in many cases and people with a biloma treated in this manner generally have a good outlook.
What else can Hepatic Biloma be?
If you feel discomfort in the right upper area of your belly and a general feeling of fullness, there could be many possible causes. These symptoms are quite vague and are common to many conditions. However, if you have recently undergone a medical procedure or suffered an injury that could have affected your biliary tree (the network of tubes that carries bile from your liver to your gallbladder and small intestine), there is a possibility you might have a condition known as a biloma.
An imaging test will help determine the exact cause of your symptoms. Some of the different medical conditions that can look like a biloma in an imaging test would include:
- Liver abscess
- Cyst
- Pseudocyst
- Lymphocele (fluid buildup in the lymph nodes)
- Seroma (swelling caused by fluid that collects in the tissues under your skin)
- Hematoma (a pool of blood that collects outside of blood vessels after surgery or injury)
It’s crucial to correctly determine if the cause of your symptoms is a biloma, as this condition often needs treatment that involves draining the fluid built up in the biliary tree. Nonetheless, other conditions like hematoma usually don’t need this type of intervention.
What to expect with Hepatic Biloma
The outlook for individuals with a biloma, a collection of bile outside of the bile duct, can depend on a few factors including where it’s located, its size, and what caused it. That said, bilomas that aren’t complicated by ongoing bile leaks often have a positive outlook. Small, symptom-free bilomas with no ongoing bile leaks are frequently treated with less aggressive approaches, which typically work well.
For individuals with bilomas that cause symptoms, a method called drainage, performed by a radiology specialist, can be very effective. These patients tend to have a good outcome. Research by Lee and colleagues showed that quickly draining symptomatic bilomas significantly improved patient health and life expectancy, and also reduced the risk of additional infection and complications.
Most of the time, once a biloma is drained, it does not come back and the prognosis is good. However, if there are large leaks of bile into the area within the abdomen, it can lead to significant health problems, often requiring immediate and intensive intervention to prevent further health decline.
Possible Complications When Diagnosed with Hepatic Biloma
Complications from biloma, a condition where bile leaks into the abdomen, can include infection, septic shock (where an infection leads to dangerously low blood pressure), the formation of pus-filled cavities, and cholestasis, which is blockage of bile flow. Researcher Lee and his team also reported instances of pancreatitis (inflammation of the pancreas), respiratory failure, and a unique condition where bile leaks into the chest through the diaphragm, in patients who have accumulated bile in their abdomen.
When it comes to percutaneous drainage of bilomas, which is a procedure to remove the accumulated bile in the abdomen through a needle or a thin tube, there may be some risks involved. These may include bleeding, infection, accidental harm to nearby organs or structures, and failure to properly drain the bile accumulation. In some cases, if there are continuous bile leaks, further procedures or surgery may be necessary.
Common Risks and Complications:
- Infections
- Septic shock
- Formation of pus-filled cavities
- Blockage of bile flow
- Pancreatitis
- Respiratory failure
- Bile leakage into the chest
- Bleeding post-procedure
- Damage to nearby organs or structures
- Inability to properly drain bile accumulation
- Continuous bile leaks
Preventing Hepatic Biloma
Bilomas, which are fluid-filled sacs in the liver, mostly happen as a result of injury to the bile ducts, either from medical procedures or trauma. Patients must be informed about the signs and symptoms that might show the development of a biloma after potential damage from trauma or medical procedures to the bile ducts. Both patients and their doctors should be alert to the possibility of a biloma in any patient experiencing non-specific stomach discomfort after trauma or procedures that involve the bile ducts. This includes any delay in recovery after operations like laparoscopic cholecystectomy, which is a minimally invasive surgery to remove the gallbladder.
Quickly diagnosing and managing bilomas can improve patient outcomes and reduce the risk of death. This is why it’s important to communicate any unusual or ongoing abdominal discomfort to your doctor, especially after a procedure or injury involving the bile ducts. This will assist your doctor to identify any potential problems quickly and take the necessary steps to manage your condition.
