Hepatic Subcapsular Biloma Complicating Electrohydraulic Therapy in a Post Liver Transplant Patient

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Introduction: Bilomas are formed either spontaneously or secondary to trauma, surgical, percutaneous, or endoscopic procedures. A subcapsular hepatic biloma is a rare complication, and typically related to surgery or trauma.

Case Description: This is a 74-year-old male with a history of cryptogenic cirrhosis and end-stage renal disease, status post liver and kidney transplantation in 2001, complicated with a 3-mm anastomotic stricture and recurrent choledocholithiasis. This required multiple ERCPs since transplantation. The patient was doing well until October 2012, when choledocholithiasis was noted incidentally on a CT scan of the chest. An elective ERCP was performed, and showed multiple stones (largest 1.5 cm) in the distal CBD and one large stone (4 x 2.5 cm) in the proximal CBD. The distal stones were extracted, and the proximal one was unable to be removed. Six weeks later, a repeat ERCP was done with removal of multiple stones and stone fragments from the distal bile duct. Spyglass cholangioscopy with electrohydraulic lithotripsy (EHL) was utilized and partially fragmented the stone. Multiple stone fragments were subsequently removed using a 15-18-20 mm Olympus balloon. A repeat ERCP done 7 weeks later demonstrated the large filling defect proximal to the anastomosis was still present. Spyglass cholangioscopy with EHL was performed with successful fragmentation of the large stone. During EHL, extensive saline irrigation was needed to clear the cholangioscopic view and multiple stones and stone fragments were completely removed using a retrieval balloon. After the procedure, the patient complained of right upper quadrant pain radiating to the back. Laboratory tests revealed no abnormalities in liver, biochemistry, or pancreatic enzymes, and no evidence of perforation on acute abdominal series. A CT scan of the abdomen revealed subcapsular biloma (5.2 x 4.2 cm) containing a focus of air, along the posterior right hepatic dome. The patient was treated conservatively and improved.

Discussion: A biloma typically develops in the area directly related to intervention in an ERCP. In this case, the subcapsular biloma formed in the posterior right hepatic dome. We believe the subcapsular biloma formed as a result of perforation of a small biliary duct due to the increased pressure from the area of treatment (proximal CBD). The high pressure in the proximal CBD arose from two sources, the electrohydraulic lithotripsy and also the injection of the saline/contrast through the catheter. This in turn led to rupture of a distal biliary ductule due to transmission of the high pres sure to the biliary system.