What happens if bile leaks into the body

What is a bile leak? A bile leak is a hole in the bile-duct system that causes bile to spill into the abdominal cavity. Bile is a substance produced by the liver to help digest fat in the food you eat. The gallbladder stores bile and is a small, pear-shaped sac located below your liver in the right upper abdomen.

Ultrasonography US and computed tomography CT cannot reliably distinguish bile from other postoperative intra-abdominal fluid collections. Magnetic resonance MRI imaging with hepatobiliary agents and MRI cholangiopancreatography provide anatomic and functional information that allows for prompt diagnosis and excludes any other concomitant complications 8.

We report a case of post-cholecystectomy bile leakage in a year-old male who presented with persistent dull abdominal pain after the laparoscopic cholecystectomy. Caucasian male patient aged 51 years was admitted to Clinic for Surgery of University Clinical Center Tuzla for elective surgery of calculous gallbladder. During surgery gallbladder empyema with microcalculosis was identified. Surgery and postoperative course went without complications.

During hospitalization patient was treated with infusions and antibiotics. Third day post-surgery patient has no health complaints, an ultrasound check-up was performed and after no free abdominal fluid was identified, abdominal drainage catheter was removed.

Patient was discharged with recommendations for antibiotic treatment. Eight day post-surgery patient is referred to Clinic for Surgery because of severe epigastric, left rib cage and left periumbilical pain. Patient was admitted to Department of Abdominal Surgery, and urgent computed tomography CT scan was performed which identified minor fluid collection by front hepatic margin.

In the course of next few days ultrasound check-up was done and no progression in size of CT-identified abdominal fluid was recorded. Patient complained of intermittent attacks of pain followed by periods without pain. Increase in body temperature of 38 degrees Celsius was noted during nighttime. Gastroenterologist was consulted and endoscopic ultrasound EUS was performed which concluded of microcholedocholithiasis, cholangitis and possible interstitial pancreatitis.

Endoscopic retrograde cholangiopancreatography ERCP was performed; after injection of contrast microcalculosis of common bile duct and detritus of pus intraluminally were identified [ Figure 4 ]. Sphincterectomy was performed during endoscopic intervention. Both right and left hepatic ducts as well as common hepatic duct are seen.

Lamellar forms of free fluid are seen in perihepatic and subhepatic region MR. Common hepatic duct with lamellar forms of free abdominal fluid in perihepatic and subhepatic region MR.

Common bile duct and passage of contrast via papilla Vateri. Pancreatic duct is of normal width. Lamellar forms of free abdominal fluid can be seen in peri- and subhepatic region MR. Radiographic finding during ERCP intervention. Common bile duct is within normal width of lumen with calculus of approx. Visible intrahepatic bile ducts are of normal width of lumen.

During procedure patient was erected into stand-up position and radioscopy confirms normal elimination of contrast out of bile ducts and pancreatic duct with no signs of elimination of calculus X-ray radioscopy. Control ultrasound examination found large abdominal fluid collection. Computed tomography CT scan with contrast was performed and fluid collection in projection of left lobe of liver and bursae omentalis is seen with characteristics of possibly inflamed lesion.

Peripancreatic exudate was seen as well [ Figure 5 ]. Pseudocystic lesion of left lobe of liver and bursae omentalis, with characteristics of inflammed lesion, although inclusions of air are present within cystic formation, which would conclude od abscess collection CT. Taking into account significant progression in size of intra-abdominal fluid collection after ERCP was performed, patient was transferred to Department of Gastroenterology and Hepatology of Clinic for Internal Diseases where percutaneous drainage of fluid collection was about to be performed.

When bile cannot flow through to the intestines, raised liver enzymes, jaundice and severe pain can result. Another problem after injury is cholangitis, an infection or inflammation of the bile ducts, causing bacteria and other waste products in the small intestine to flow upward causing infection.

Cholangitis can be life threatening if not treated. Leakage of bile eventually causes symptoms of pain and breathing difficulties. Because of the serious consequences of a bile leak, which poisons the body and can cause death, any such symptoms following surgery need to be promptly investigated.

Discharging a patient with any of these symptoms may be medically negligent. An even more serious situation may be symptoms that do not show up immediately. This is a situation where there should be no waiting.

However, upon visualization, gallbladder was gangrenous and conversion to an open subtotal cholecystectomy became necessary due to inability to safely dissect inflammatory adhesions and failure to clearly delineate the anatomy. The gallbladder remnant was closed and a Jackson-Pratt drain was placed in the gallbladder fossa. The patient initially did well but, on the second postoperative day, a significant amount of bile was noticed in the drain.

An endoscopic retrograde cholangiopancreatography ERCP was performed and revealed a bile leak from the cystic duct Figure 1. During her follow-up visits, persistent leakage of bile was noted despite clinical return to baseline health status. At 8 weeks another ERCP was performed which confirmed an ongoing bile leak from the cystic duct stump. As the bile leak persisted, treatment options were discussed with gastroenterologist and interventional radiologist. Surgical option was also considered as the last resort.

After discussion 5 weeks from last ERCP , the tract was accessed by interventional radiologist. Contrast study showed that the covered stent was not covering the origin of the cystic duct. Follow-up cholangiogram demonstrates interval decrease in patency of the cystic duct. A pigtail drain was adjacent to the cystic duct. The pigtail drain was clamped after the bile drainage stopped at 1-week follow-up. On subsequent ERCP done 2 weeks later, occlusion cholangiogram revealed no evidence of bile leak Figure 4 and the stent and drain were removed.

The patient was seen 4 months later with no further biliary complications. Laparoscopic cholecystectomy is one of the most commonly performed operations in the world. Bile leak from the cystic duct stump remains a significant complication of this operation [ 1 , 2 ].

Bile peritonitis, subhepatic abscesses, bile duct stricture, and perihepatic inflammation leading to fibrosis have all been associated with bile leaks [ 3 ].

The median time for resolution of the leak was 3 days range 1—39 days [ 5 ]. Kaffes and colleagues [ 5 ] reported that stent insertion alone for postcholecystectomy bile leak is superior to sphincterotomy alone, because fewer patients required additional intervention particularly surgery to control the leak.

Other options reported include injection of glue or coils either via endoscope or transhepatically. Seewald et al. Other authors have also reported successful endoscopic glue injection for cystic duct leak [ 6 ]. Combination of cyanoacrylate glue and angiographic coils has also been deployed via endoscope at ERCP to resolve cystic duct leak after failed operations [ 8 ]. Percutaneous trans hepatic deployment of Hydrocoil into the cystic duct stump has been reported as well [ 9 ].