A 63 y.o. woman with biliary cancer and a duodenal stent presents with peritonitis and is in shock.

what do you notice on her CT?

Our patient had a biloma.  Her gallbladder had ruptured due to tumor and there was a collection of free bile in the abdomen with gallstones visible. Biloma more commonly occurs after cholecystectomy with an incidence of 0.3-2%. Liver biopsy, abdominal trauma and surgery can also cause leakage of bile into the abdomen. Post operative fluid collections like a seroma or lymphocele can have the same appearance on CT  with water attenuation <15 HU. 

The sensitivity of US is only 70% in detecting a biloma.  CT scan is 90% sensitive, MRI 95% sensitive and HIDA scan is 97% sensitive.

Where it says consult internist substitute “ED physician”. There are many causes of RUQ pain with biloma being one of the rarest. Causes of RUQ pain vary in different parts of the world with amebic liver abscesses occurring commonly in Mexico, India, Central and South America.

Tests available to evaluate causes of RUQ pain include blood tests and imaging.  Most often a RUQ US is ordered first. CT and MRI are also useful followed by  EUS of the pancreas. Lab values like lipase may not always help since lipase can be elevated with gallstones.

A strawberry gallbladder or cholesterolosis, refers to the surface appeareance of the gallbladder due to multiple small collections of triglycerides and cholesterol esters within the lamina propria

Adenomyomatosis of the gallbladder also shows cholesterol deposits within a thickened gallbladder wall. A comet tail sign can be seen on US.

Our patient she was septic from an infected biloma and underwent drainage of the fluid.  It grew Klebsiella and streptococcus.  The pt elected to go home on hospice.

Yousaf M, Souza R, Chaudhary F, Ehsan H, et al. Biloma: a rare manifestation of spontaneous bile leak. Cureus 2020 may 12 (5) e8116.

Sung H., Hyun Youn Han, Hee J.  comet tail artifact on UL: is it a reliable finding of benign gallbladder diseases? Ultrasonography 2019 Jul;38(3):221-230.

Vadvala H, Arellano R. Imaging and intervention of biliary leaks and bilomas. Dig dis Interv. 2017;1:14-21.

Cella Valle V, Eshja E, Bassi E. J Ultrasound 2015;18:293-296.

Avegno J, Carlisle M. Evaluating the ptient with right upper quadrant abdominal pain. Emerg Med Clin North Am. 2016 My;34(2):211-28