postcholecystectomy bilomas are relatively uncommon with a reported incidence of about 2.5% , and most often present with right upper quadrant pain and fever within seven days of the operation .
the authors report a case of a cholecystectomy performed in a 35-year - old female which resulted in a biloma , presenting 11 days postoperatively with gastric outlet obstruction .
the literature is reviewed to suggest the optimal management and treatment plans for this complication .
this patient was successfully managed with radiologic intervention for the treatment of a biloma and resulting gastric outlet obstruction after open cholecystectomy .
although uncommon , bilomas may present in an unusual manner such as with gastric outlet obstruction . as with early bilomas , they may be treated successfully with interventional radiologic techniques .
although it has been reported as occurring spontaneously with incarcerated choledocholithiasis , it is usually due to an iatrogenic injury following cholecystectomy .
the incidence of post laparoscopic cholecystectomy biloma , in the two largest series , is about 2.5% .
to our knowledge , this is the first reported case of gastric outlet obstruction secondary to a post cholecystectomy biloma .
a 35-year - old hispanic female underwent a cholecystectomy that began using laparoscopic techniques , but was converted to open cholecystectomy due to bleeding from a small branch of the cystic artery which was easily controlled after laparotomy was performed .
common bile duct , cystic duct and cystic artery were in normal anatomic location , and no anatomic abnormalities were identified . the patient was discharged four days after the operation .
she returned one week later with complaints of nausea , vomiting , as well as right and left upper quadrant pain .
there was no reported change in the color of her stools , urine or skin .
liver function tests showed elevated alkaline phosphatase , ast , alt , with normal total and conjugated bilirubin .
an abdominal ultra - sound study demonstrated large upper abdominal fluid collections bilaterally . computed tomography ( ct ) of the abdomen and pelvis showed a large fluid filled structure along the dome of the liver , consistent with a subcapsular fluid collection ( figure 1 ) .
there was also marked dilatation of the stomach secondary to kinking of the duodenum by the displaced liver and subcapsular fluid mass .
further management included an upper gastrointestinal series that revealed extrinsic compression of the proximal duodenum , creating a partial gastric outlet obstruction ( figure 2 ) .
the patient subsequently underwent percutaneous pigtail catheter drainage placed under ct guidance , which spontaneously yielded 1.5 liters of bilious fluid . a hepatobiliary iminodiacetic acid ( hida ) scan obtained one day after the ct guided drainage concluded that there was a bile leak in the region of the gallbladder fossa ( figure 3 ) .
endoscopic retrograde cholangiopancreatography ( ercp ) showed that the second portion of the duodenum was normal , with a prominent minor ampulla , and a normal sized bile duct with no apparent leak .
the patient had a sphincterotomy performed for decompression , and was subsequently discharged with catheter drainage .
ten days after discharge , the catheter became dislodged and the patient complained of recurrent pain . she was hospitalized and another ercp was performed .
it revealed a leak from a small branch of the right hepatic duct ( figure 4 ) .
postoperative computed tomographic scan of the abdomen demonstrates a fluid collection on the right side of the liver .
upper gastrointestinal series image reveals slow passage of contrast through the pylorus , consis - tent with a gastric outlet obstruction caused by inferior displacement of the liver secondary to a biloma .
ercp shows a small leak from an accessory hepatic duct ( arrow ) . during this procedure ,
postoperative biloma usually presents in a delayed fashion ( about seven days ) with right upper quadrant pain ( ruq ) and fever . the patient in this case presented with the novel finding of gastric outlet obstruction .
ct scan or ultrasound usually establishes the diagnosis of a fluid collection ; however , these tests are not specific .
this differentiation is complicated by the fact that there is usually some fluid in the gallbladder fossa 3 - 5 days post cholecystectomy .
the performance of an intraoperative cholangiogram can demonstrate aberrant anatomy , thus decreasing the likelihood of a biliary tract injury .
radionuclide scanning ( hida ) demonstrates continuity of the fluid collection with the biliary tree .
hematomas , the other major differential diagnosis , are hyperintense on both t1 and t2 images .
if the ercp does not demonstrate the leak , it may be coming from an accessory biliary duct , or a duct of luschka in the liver bed .
ercp with stent placement , percutaneous drainage , and nasobiliary drainage have been used alone or in combination .
recommend an algorithmic approach to the treatment of postoperative biloma starting with percutaneous drainage and ercp to identify the source of the leak , and subsequent sphincterotomy and stent placement if the biloma does not resolve within ten days .
these methods are effective , but not perfect , as the biloma may recur after the intervention , thus requiring a second interventional procedure .
suggest that bile leaks without associated abdominal collections should be first identified by ercp followed by sphincterotomy and/or stent placement .
these authors reserve surgery for cases of major bile duct injury when percutaneous drainage and endoscopic management fail initially . in the case presented , while a leak was observed on hida scan , ercp did not initially identify the site of injury .
percutaneous drainage evacuated the fluid collection accompanied by sphincterotomy which resulted in spontaneous resolution after several days .
ercp is appropriate to identify the site of leak with percutaneous drainage used as an initial therapeutic maneuver .
major bile duct injuries which pre - sent as bilomas and are identified by ercp may require early surgical intervention .
if the biloma does not resolve , then sphincterotomy and stent placement may result in resolution of the leak .
 background : postcholecystectomy bilomas are relatively uncommon with a reported incidence of about 2.5% , and most often present with right upper quadrant pain and fever within seven days of the operation . 
 there are a number of approaches to the treatment of this uncommon lesion.case report : the authors report a case of a cholecystectomy performed in a 35-year - old female which resulted in a biloma , presenting 11 days postoperatively with gastric outlet obstruction . 
 the literature is reviewed to suggest the optimal management and treatment plans for this complication.results:this patient was successfully managed with radiologic intervention for the treatment of a biloma and resulting gastric outlet obstruction after open cholecystectomy.conclusion:although uncommon , bilomas may present in an unusual manner such as with gastric outlet obstruction . as with early bilomas 
 , they may be treated successfully with interventional radiologic techniques . 
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INTRODUCTION
CASE REPORT
DISCUSSION