Posttraumatic Intrahepatic Bilioma

Abstract

Blunt injury abdomen causing biliary injury is rare in children. Collection of bile within or outside the liver after biliary injury is called bilioma. CT scan images of late presenting intra-hepatic bilioma are shown.

Case History

A 7-year-old boy sustained road traffic accident causing blunt injury abdomen and bone fractures. He was resuscitated, and computerized tomogram (CT) of abdomen showed grade II laceration of the right lobe of the liver and the spleen (Fig. 1). He was treated conservatively for 10 days and referred to our center for orthopedic management. He was anemic and had generalized edema. There was abdominal distension and tenderness. Liver function test was normal except low albumin (2.5 g%). Packed cell and plasma transfusion was given. Contrast CT scan of the abdomen showed a thick walled fluid collection in the right lobe of the liver measuring 107 × 86 × 70 mm suggestive of chronic hematoma or bilioma (Fig. 2a). There was an old laceration of the spleen with free fluid in the peritoneal cavity. Diagnostic laparoscopy showed 150 ml of serosanguinous fluid in the peritoneum, omentum adherent to the spleen and smooth liver surface. Peritoneal drainage drained about 50 ml of the serosanguinous fluid for 3 days and was removed later. He was managed conservatively for 6 weeks and submitted for repeat CT scan which showed enlarged liver with the cystic lesion measuring 135 × 95 × 106 mm (Fig. 2b). There was no calcification, solid elements, or obvious biliary duct injury. Diagnostic aspiration and 12 F pigtail catheter was inserted under guidance which drained 750 ml of bile. The catheter was kept for 2 weeks and removed. Ultrasonogram showed complete resolution of the cavity.

Fig. 1.

CT scan of abdomen showing linear liver laceration

Fig. 2.

CT scan showing formation of bilioma (a) and further increase in size on follow-up (b)

Discussion

Biliomas are localized collection of bile that occur after injury to intrahepatic or extrahepatic bile ducts and is very rare in children. Initially, bile leaks are usually associated with hematomas, but, over time, blood clots are replaced by bile [1]. Most biliomas are single, well-defined collections within the liver and may take time to develop as in our case. Serum ALT levels can be elevated in biliomas [2]. Persisting intrahepatic bilioma can be managed by needle aspiration, drainage or endoscopic retrograde cholangiopancreatography (ERCP), and stenting [3, 4]. We stress clinical re-evaluation and imaging in needy cases of blunt injury abdomen to detect bilioma.