Drains, Stents, or Standby? An Algorithmic Approach to Biloma Management

Learning Objectives:

1. Review biloma pathophysiology and most common etiologies


2. Recognize the clinical and imaging features of bilomas that determine when various interventions are indicated


3. Apply an algorithmic decision-making framework to biloma management and describe the interventional approach to biloma treatment

Background: Bilomas are encapsulated collections of bile external to the biliary tree that form after bile duct injury, most commonly due to abdominal trauma, direct iatrogenic injury (post-hepatobiliary surgery, endoscopy), or ischemic injury (post-transarterial embolization, post-transplant hepatic artery thrombosis) {1}. Interventional radiologists play a key role in biloma management, especially when biloma superinfection occurs or ductal leakage is persistent {2,3}. Biloma management often requires a complex multidisciplinary treatment approach, and varies significantly between patients, with limited literature to guide decision-making. This educational exhibit will offer an algorithmic approach to biloma management utilizing a range of case examples.

Clinical Findings/Procedure Details: Clinical presentation and imaging features dictate biloma management. Asymptomatic, sterile bilomas are often identified incidentally and should be observed. Symptomatic bilomas may present with right upper quadrant pain or elevated liver function tests related to mass effect, cholestasis, and/or inflammation, or systemic signs of infection {4}. Radiologic workup may include ultrasound, CT, MRCP, or HIDA, and the benefits of each modality will be discussed.

Treatment of larger and/or infected bilomas may require percutaneous or other forms of drainage. Biloma persistence despite drainage suggests ongoing bile leak and/or ductal communication in the setting of a downstream biliary obstruction and may require biliary diversion for resolution, which may be achieved with ERCP and internal stenting or percutaneous internal/external biliary drainage {5-8}.

Case examples will illustrate the spectrum of biloma presentations and interventional approaches, focusing on those requiring intervention, including percutaneous drainage with resolution, drainage with conversion to an internal/external biliary drain, drainage with placement of a separate internal/external biliary drain, and combined endoscopic and percutaneous treatments.

Conclusion and/or Teaching Points: This exhibit highlights the spectrum of biloma presentations and, through a single institution framework, reinforces a practical, algorithmic, and patient-centered approach to optimizing biloma management.