Biloma : An Unusual Complication in a Patient with Calculus Cholecystitis

A biloma is an encapsulated collection of bile located in the abdomen. It usually occurs spontaneously or can be secondary to traumatic injury (hepatobiliary surgery) and in rare condition it can occur as complication of cholecystitis and cholangiocarcinoma. The diagnosis can be suggested on the basis of patient’s medical history, clinical symptoms and imaging findings but final definitive diagnosis can only be made by aspiration of the content and biochemical analysis. We here report a case of 62 years male patient admitted with acute abdominal pain in the right hypochondrium caused by a spontaneous biloma. We discuss the role of the various diagnostic imaging techniques, particularly which of ultrasound and CT. The biloma was identified on computed tomography in this case.


INTRODUCTION
Biloma is defined as a bile collection, either encapsulated or not, outside the biliary tree, with intra-or extrahepatic location, generally of iatrogenic nature or resulting from abdominal trauma. 1,2The word "biloma" was first utilized by Gould & Patel 3 in 1979, but there are descriptions of such an entity since the century XIX. 4 Spontaneous rupture of the biliary tree is rarely observed, sometimes being associated with choledocolithiasis. 1,5he detergent activity of bile acids provokes chronic inflammation that, on its turn, causes adhesions, leading to a possible loculated appearance of the collection. 2 Clinically, abdominal pain, distention, peritonitis, jaundice and, in more severe cases, sepsis, may occur. 1,2,5,6The mean time between symptoms onset and the diagnosis is one to two weeks. 2Considering the rarity of such condition, the authors describe the present case and review this clinical entity.

CASE REPORT
A male, 62 years old, previously healthy has presented right hypochondrium pain for 5 days.At clinical examination, the patient was icteric (3+/4+) and afebrile.

Figure 2: Post contrast axial CT scan at the level of neck of gallbladder showing small hyperdense calculus at neck of gall bladder.
There is minimal thickening of wall of gall bladder with subcapsular collection in liver.

DISCUSSION
Gallbladder perforation is uncommon condition.Gall bladder perforation is seen in 2-10% of acute cholecystitis cases. 7This complication is rare these days with incidence of 0.8% due to increase in cholecystectomies in modern surgical practice. 8The pathophysiology leading to gallbladder perforation include cystic duct obstruction, stasis of bile that leads to increase in the intravesicular pressure, gallbladder dilatation and eventually perforation. 7,9Niemeier classified gallbladder perforation into acute (Type I), subacute (TypeII) and chronic (Type III).In type I perforation there is generalized peritonitis, in subacute (Type II) there is localized peritonitis or pericholecystic abscess, and in chronic (Type III) there is a cholecystoenteric fistula. 10If there is rupture along the under surface of gallbladder there will be peritonitis with extraluminal fluid collection.Intrahepatic biloma or abscess may form if it occurs along the liver surface of the gallbladder.However Intraheptic bilomas due to gallbladder perforation is rare. 9erlapping symptoms can be seen in both complicated and uncomplicated cholecystitis which make early diagnosis difficult but have important implications for patient management.Complicated cases need open cholecystectomy rather than laparoscopic cholecystectomy. 7,11This patient underwent open cholecystostomy with placement of drainage tube.Patient was discharged after resolution of the symptoms.

CONCLUSION
Subcapsular biloma is one of the complication of perforated acute cholecystitis.Early detection of these complication has significant impact on clinical management.Imaging and interventional radiology has an important role in the diagnosis and management Laboratory tests included: Gamma-Glutamyl Transferase(GGT): 340 U/L, direct bilirubin levels: 8.8 mg/dl and lipase levels: 205 U/L.Microbiological study presented negative results.Ultrasonography (US) demonstrated thickened and edematous gallbladder wall with subcapsular collection in liver with diagnosis of calculus cholecystitis.Computed tomography (CT) confirmed the distended gallbladder with perforation in fundus and fistulous communication with subcapsular collection in liver and thus the patient was submitted to laparotomy, which confirmed the tomographic report.

Figure 1 :
Figure 1: Post contrast axial CT scan at the level of fundus of gallbladder showing perforation at the fundus with subcapsular collection in liver.