RESUMO

Bilomas are collections of bile outside the biliary tree. The most frequent etiologies are iatrogenic and trauma. Cases of spontaneous or atraumatic bilomas are rare. Management of bilomas depends on the size and location and may include monitoring only; if the size is < 4 cm, there may be percutaneous or endoscopic intervention. The use of antibiotics depends on the clinical status of the patient. We describe the case of a man who presented with a spontaneous biloma eight years after laparoscopic cholecystectomy and, in addition to signs of choledocholithiasis, a stricture of the common bile duct. In patients with symptoms of biliary pathology, the diagnosis of biloma should be considered even without a history of trauma or recent surgery to initiate appropriate treatment early. Many cases are asymptomatic and resolve spontaneously but occasionally require percutaneous or endoscopic management.

Los biliomas son colecciones de bilis fuera del árbol biliar. Las etiologías más frecuentes son la iatrogenia y el trauma. Los casos de biliomas espontáneos o atraumáticos son poco frecuentes. El manejo de los biliomas depende del tamaño y la localización y puede incluir vigilancia solamente, si el tamaño es < 4 cm, puede haber intervención percutánea o endoscópica. El uso de antibióticos depende del estado clínico del paciente. Presentamos el caso de un hombre que presentó un bilioma espontáneo 8 años después de una colecistectomía laparoscópica que, además de signos de coledocolitiasis, presentaba una estenosis del conducto biliar común. En los pacientes con clínica de patología biliar debe considerarse el diagnóstico de bilioma aun en los casos que no presenten antecedente de trauma o cirugía reciente con el fin de iniciar el tratamiento adecuado tempranamente. Muchos casos son asintomáticos y se resuelven espontáneamente, pero en ocasiones requieren manejo percutáneo o endoscópico.

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RESUMO

One of the rarest complications of the hepatic trauma is a biloma, defined as an abnormal bile collection outside the biliary tree, with intra or extrahepatic localization. Patients with biloma do not present with specific clinical features, which demands a challenging radiological diagnosis. In this report, we present a case of biloma due to blunt hepatic trauma, in which the patient experienced a changing symptomatic spectrum after surgery and had an interesting radiological investigation. The clinical course, imaging features, and management of this case are discussed. (AU)

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RESUMO

Objetivo. Presentar el segundo caso descrito en la bibliografía de bilioescroto secundario a bilioma retroperitoneal espontáneo y mostrar a su vez de manera escalonada el tratamiento que se le suministró hasta la resolución completa del cuadro. Caso clínico: Varón de 69 años que debutó con dolor escrotal derecho en relación con bilioescroto secundario a bilioma retroperitoneal espontáneo. Discusión: El bilioma retroperitoneal es un hecho poco habitual; generalmente se debe a complicaciones quirúrgicas o de procedimientos invasivos (intervencionismo radiológico, CPRE y esfinterotomía endoscópica), aunque puede ser consecuencia de roturas espontáneas de la vesícula o la vía biliar principal. La bilis en el retroperitoneo puede discurrir hasta el escroto, originando la rara entidad conocida como bilioescroto. Generalmente se presenta simulando una hernia inguinal incarcerada. No existe un manejo estandarizado de esta patología ya que está escasamente descrita.

Objective: To present the second case described in the literature of biliscrotum secondary to spontaneous retroperitoneal biloma and show a sequential treatment that we provided until complete resolution. Clinical case: We report the case of a man 69 years old, who debuted with right scrotal pain related to biliscrotum secondary to spontaneous retroperitoneal biloma. Discussion: The retroperitoneal biloma is a rare event, usually due to surgical or invasive procedures complications (radiological interventionism, ERCP and endoscopic sphincterotomy), although it may be the result of spontaneous rupture of the gallbladder or bile duct. Bile in the retroperitoneum may extend into the scrotum, causing the rare condition known as biliscrotum. Usually it occurs simulating an incarcerated inguinal hernia. Does not exist a standardized management of this condition because is poorly described.

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RESUMO

BACKGROUND: Non-traumatic spontaneous rupture of the biliary tract and retroperitoneal accumulation (retroperitoneal biloma) is an extremely rare condition. CLINICAL CASE: A 57 year-old woman with no known biliary disease, started with intense pain in the right abdomen 30 days prior to consultation. She also had jaundice (4+). The initial hepatobiliary ultrasound reported choledocholithiasis and retroperitoneal fluid collection, which was confused with a peri-renal abscess. Guided puncture was performed and the presence of bile was evident. Dilation of the bile duct was observed in the computed tomography. The patient underwent laparotomy to correct both conditions. CONCLUSION: The retroperitoneal biloma, also called choleretroperitoneum, is of multifactorial origin. Clinical presentation is non-specific, with diffuse abdominal distension and pain in all patients. The diagnosis is made based on ultrasonography and computed tomography, and can even be diagnosed intra-operatively. The treatment is based on liquid bile drainage and correction of the leak.

Assuntos

RESUMO

Bilioma é qualquer coleção de bile fora das vias biliares. Geralmente, resulta de complicações cirúrgicas e trauma abdominal. A ocorrência espontânea é rara, ocasionalmente associada a coledocolitíase. Relata-se um caso de bilioma espontâneo, cujo diagnóstico foi confirmado radiologicamente. À laparotomia, observou-se bilioma retroperitoneal. A colangiografia transoperatória não evidenciou fístula. Após drenagem, o paciente teve boa evolução e alta hospitalar.

Biloma is defined as any collection of bile outside the biliary tree, usually resulting from surgery complications and abdominal trauma. Spontaneous occurrence of bilomas is rare, occasionally associated with choledocolithiasis. The present report describes a case of spontaneous biloma, whose diagnosis was radiologically confirmed. At laparotomy, the presence of a retroperitoneal biloma was observed. Intraoperative cholangiography has not demonstrated the presence of fistula. After drainage, the patient progressed well and was discharged.

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Introducción: El biloma se define como la fuga de bilis intrahepática, extrahepática y a veces retroperitoneal, asintomático o de sintomatología variable, la presencia del biloma subcapsular hepático en un paciente con pancreatitis crónica no ha sido informada en la literatura. Caso clínico: Hombre de 52 años de edad, alcohólico. Se realiza colecistectomía laparoscópica por colecistolitiasis sintomática, reingreso precoz por presentar vómitos, distensión abdominal, ictericia y tumor abdominal doloroso en hemiabdomen superior, el ultrasonograma (US) y la tomografía computarizada (TC) helicoidal abdominal muestran una colección en lóbulo hepático derecho, se realiza drenaje percutáneo (DP), en la colangiopancreatografía retrógrada endoscópica (CPRE) no se observa fuga biliar, anatomía biliar normal, conducto pancreático principal dilatado difusamente con estenosis dispersas. Se realiza esfinterotomía y drenaje. Conclusiones: No existen reportes de la coexistencia entre biloma subcapsular hepático y pancreatitis crónica luego de la colecistectomía laparoscópica, no pensamos que esta sea una relación casual, se exponen factores que justifican la misma.

Background: Bilomas is the intra-hepatic, extra-hepatic and sometimes retroperitoneal collection for bile leak, variable clinic or asymptomatic. However, the clinical association between hepatic sub-capsular bilomas and chronic pancreatitis never has seen to be reports elsewhere in the literature. Clinical case: A 52-year-old alcoholic man who was operated of laparoscopic cholecystectomy for symptomatic cholelithiasis, readmitted for vomiting, abdominal distension, ictericia, abdominal pain tumour in superior abdomen, the ultrasound(US) and helicoidally computer tomography(CT) show the collection in right hepatic lobule, it was evacuated for percutaneous drainage, in endoscopic retrograde cholangiopancreatography(CPRE) no observed bile leak, biliar tree was normal, the main pancreatic duct appeared diffusely dilated with scattered strictures, and finished with endoscopic sphincterotomy and drainage. Conclusions: There are no reports of a clinical association between hepatic sub-capsular bilomas and chronic pancreatitis after laparoscopic cholecystectomy. We believe that there is a physiopathological relationship between then and exposed the facts.

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