Physical examination revealed a well-nourished woman. Her vital signs were normal except for an elevated temperature of 99.1 F. She had tenderness to palpation in the epigastrium and left upper quadrant of the abdomen. She was not jaundiced. Laboratory studies revealed a mildly elevated white cell count and normal liver enzymes.
Studies investigating radioscintigraphic evidence of bile leak post-op in both symptomatic and asymptomatic patients suggest that perihepatic collections are common. Gilsdorf (3) recorded a leak rate of 44% and Rayter (4) recorded perihepatic leaks in 31% of patients in the first 24 hours post-op. In Rayter's study however, only 1 in 25 patients with leaks required percutaneous drainage. The remaining 24 patients' collections resolved spontaneously. In addition, Rayter noted that ultrasound (US) detected only half of the smaller collections (7-12ml) confirming the higher sensitivity of radioscintigraphy for detecting bile leaks.
Not only is radioscintigraphy more sensitive for detecting bile leaks, it is also more specific. Ultrasound and CT can detect sizeable collections within the abdomen but these techniques cannot differentiate between bile, serum, and blood; and cannot demonstrate whether the fluid collection communicates with the biliary tree (5). In a study of 1697 patients who underwent laparoscopic cholecystectomy at Cedars Sinai Hospital (6), 27 patients had post-laparoscopic cholecystectomy nuclide scans because of a suspicion of biliary complications, most of whom had nausea, pain and low grade fever. Of these 27 patients, 7 were found to have bile leaks only 3 of whom had fluid collections identified on ultrasound or CT. These collections were drained percutaneously. Of the remaining 4, 2 had negative ultrasound scans and were treated successfully with antibiotics and one had a negative ultrasound and ERCP but positive CT and underwent operative drainage. The early post-op course was apparently similar in those with and without complications with patients complaining of nausea and pain. They concluded that radionuclide scans are a sensitive and non-invasive test for post-op biliary complications and considered hepatobiliary radioscintigraphy to be a pivotal component of an algorithmic approach towards the management of post-op complications.
95% of biliary tree leaks are iatrogenic in origin, most arising due to complications of surgery to the biliary tree. Other causes include trauma to the abdomen (usually resulting in injury to the liver rather than disruption of the biliary tree), spontaneous perforation of the gallbladder and secondary to PTCA. Iatrogenic leaks may arise from damage of biliary radicles during dissection of the gallbladder, division of an accessory bile duct, dislodgement of a loosely placed clip or ligature from the cystic duct stump or injury to the hepatic duct or common bile duct. The usual radioscintigraphic findings of a biliary leak are normal liver function and radioactivity outside the biliary tract and bowel. Different patterns of extravasation have been described (5-9). Perihepatic collections are the most common and usually resolve spontaneously. Normally the small bowel is visualised unless all the bile excreted by the liver is being extravasated. Bile leakage into the peritoneal space results in biliary ascites, a serious situation requiring prompt drainage. More localised collections of biliary radioactivity may result where there are post-op adhesions and scarring (7). Extravasation from biliary radicles in the gallbladder bed or severance of an accessory bile duct may result in a collection of radioactivity in the gallbladder fossa which becomes walled off (a biloma). Singh reported a case where a biloma in the gallbladder fossa closely resembled normal visualisation of the gallbladder and suggested that physicians should be alert to scrutinize and seek knowledge about the past histories of patients (10).
In some cases abnormal activity identified in the right upper quadrant of the abdomen is difficult to differentiate between small bowel and biliary leak. Techniques to help separate one from the other include oblique views, repeated images after administration of water to wash out duodenal activity, dynamic displays, standing views to promote intestinal transit and displace bowel loops downward (11) and delayed images. Very small leaks or slow leaks may require extra delayed images. Of 23 patients with biliary leaks after trauma, Weissmann (12) reports that 11 were visible only after one hour of imaging. Fortunately, radioactivity in abnormal bile collections persist even after liver parenchyma and biliary tract are no longer visible, further aiding in their recognition.
The early detection of clinically significant bile leaks is important to minimize patient morbidity. Sequelae of bile extravasation include subhepatic fluid collection ( many of which are clinically insignificant and resolve spontaneously (3), abscess formation, fistula formation and at worst biliary ascites. Radionuclide scans have been shown to be the most sensitive imaging tachnique to identify early leakage and are non-invasive. These studies should be considered early in the post-op management of those patients who develop fever, jaundice, abdominal pain or profuse bilious drainage and are suspected of having a significant bile leak. The extravasation of small quantities of bile however occurs commonly after surgery and is of little significance.
2. Hawasli A, Lloyd LR. Laparoscopic cholecystecomy-the learning curve:report of 50 patients. Am Surg 1991;57:542-545.
3. Gilsdorf JR, Phillips M, McLeod MK. Radionuclide evaluation of bile leakage and the use of subhepatic drains after cholecystectomy. Am J Surg 1986;151:259-264.
4. Rayter Z, Tonge C, Bennett CE. Bile leaks after simple cholecystectomy. Br J Surg 1989;76:1046-1048.
5. Kapoor VK, Ibrarullah M, Baijal SS. Cholecystectomy and drainage : ultrasonographic and radioisotopic evaluation. World J Surg 1993;17:101-104.
6. Kulber DA, Berci G, Paz-Partlow M, Ashok G, Hiatt J. Value of earlly cholescintigraphy in detection of biliary complications after laparoscopic cholecystectomy. Am Surgeon 1994 Mar; 60 (3):190-3.
7. Siddiqui AR, Ellis JH, Madura JA. Different patterns for bile leakage following cholecystectomy demonstrated by hepatobiliary imaging. Clin Nucl Med 1986;11:751- 753. 8. Lawrence SK and Debelke D. Bile leak after laparoscopic cholecystectomy. AJR 1992;158:1385-6.
9. Rosenberg DJ, Brugge WR, Alavi A. Bile leak following an elective laparoscopic cholecystectomy: The role of hepatobiliary imaging in the diagnosis and management of bile leaks. Clin Nucl Med 1991;32:1777-1781.
10. Singh A, Valle G. Pseudonormal hepatobiliary scintigraphy in a patient with a bile leak. Clin Nucl Med 1990 Nov;15:843.
11. Lette J, Morin M, Heyen F. Standing views to differentiate gallbladder or bile leak from duodenal activity on cholescintograms. Clin Nucl Med 1990; 4:231-236.
12. Weissmann HS, Chun KJ, Frank M. Demonstration of traumatic bile leakage with cholescintigraphy and ultrasonography. AJR 1979;133:843.
Click here to go to Joint Program in Nuclear Medicine home page and Copyright notice.