Pthc Collection 265
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Laceration of the intrahepatic bile ductal system can result from iatrogenic injury during cholecystectomy. Injury to the biliodigestive anastomoses after cholecystectomy results in potential leakage of the bile ducts. Laparoscopic cholecystectomy has become the gold standard treatment for cholelithiasis and has shown to be a safe and reliable technique [25]. PTC and MRCP are the modalities of choice for the evaluation of biliary intra-abdominal collections. Although MRCP is also the gold standard for the evaluation of biliary injuries, US is simpler to perform and readily available. Both CT cholangiography and US may be used preoperatively to identify biloma/pseudocyst formation, gallstone disease, cholangiocarcinoma, and T-tube stent insertion [26]
A cystic communication is demonstrated in this patient rather than a bile leak. US and CTC showing a collection of bilious fluid in the abdomen with a cystic calculus (inhomogeneous, with acoustic shadowing) posterior to the gall bladder. Negative findings for the biliary tree on CT and infection. Patient symptoms: fever, back pain for 7 days. Findings on US: subhepatic fluid in the right iliac fossa, gall bladder (or its neck), renal calculi with cortical kidney window in the left kidney. Given that the patient had a retroperitoneal collection with the right iliac fossa the likely diagnosis at this point would be pre-pancreatic abscess. A surgical drainage was performed. Pathology report: calculus of gall bladder
Even though the leak, percutaneous drainage, and stent were placed at different hospitals, the biliary tree had become infected as shown by the walled-off collection as well as the abscess formation. The past iatrogenic bile duct injury most likely led to the percutaneous drainage for which the final pathologic diagnosis was MRCP-IPMN, with no evidence of malignancy. After the stent removal and abscess drainage, the patient was discharged the next day in stable condition. d2c66b5586
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