Spontaneous Bile Leak in a Patient Without Recent Abdominal Surgery or Trauma

Abstract

Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.

Fístula Biliar Relacionada À Coledocolitíase

“…Existem algumas inconsistências na literatura quando se trata da definição de fístulas biliares espontâneas 5 . Alguns estudos definem como vazamento de bile onde uma causa específica permanece não identificável e geralmente é diagnóstico de exclusão 5,11 .…”

“…Muitos estudos relatados, não demonstraram o local do extravasamento ou relatam casos com fístula biliar após algum procedimento [5][6][7]11 . Dessa maneira, a literatura é escassa com relação à fístula biliar espontânea relacionada a coledocolitíase.…”

“…Em geral são mais comumente decorrentes de complicações em colecistectomias 2 , podendo estar relacionadas a traumas, operações hepáticas, biópsias, abscessos, e drenagens endoscópicas e percutâneas da via biliar 3,4 . Há pouca evidência científica demonstrando que fístulas biliares podem estar relacionadas à doenças da vesícula biliar ou coledocolitíases 5 .…”

Bile Leak from the Cystic Duct during Endoscopic Retrograde Cholangiopancreatography

“…Although bile leaks are most often seen as a complication of cholecystectomy, only 0.5% of patients that undergo a cholecystectomy develop a bile leak. 1 Most patients typically present 2 to 10 days post-cholecystectomy. 2 A bile leak can cause biliary fistula, peritonitis, or subhepatic/subphrenic collections of bile.…”

“… 2 A bile leak can cause biliary fistula, peritonitis, or subhepatic/subphrenic collections of bile. 1 Because bile leaks can lead to death, prompt intervention should be needed. 1 …”