Case Author(s): Stephanie P.F. Yen, M.D. and Barry A. Siegel, M.D. , 5/8/98 . Rating: #D2, #Q4

Diagnosis: Intraperitoneal biliary leak

Brief history:

12-year-old boy status post liver transplant now with mild jaundice and increasing ascites.


Sequential anterior abdominal images

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Full history/Diagnosis is available below

Diagnosis: Intraperitoneal biliary leak

Full history:

12-year-old boy who is one month status post liver transplantation for cystic fibrosis. The patient's biliary anastomosis is via a choledochocholedochostomy. The patient now presents with mild jaundice (serum bilirubin 3.0 mg/dL) and increasing ascites. Paracentesis performed the day before revealed an ascitic fluid bilirubin concentration of 27 mg/dL. Approximately 5 liters of ascitic fluid was removed. The patient underwent a T-tube cholangiogram on 5/5/98; this study revealed that the T-tube was positioned out of the biliary tree, and the T-tube was subsequently removed. Hepatobiliary scintigraphy was requested to confirm a biliary leak.


1.2 mCi Tc-99m mebrofenin i.v.


Following the intravenous administration of Tc-99m mebrofenin, sequential anterior abdominal images were obtained through 60 minutes. There is prompt, uniform accumulation of tracer by the liver. At 5 minutes following administration of the radiopharmaceutical, a small amount of activity is seen inferior to the tip of the right hepatic lobe. Over the course of the remainder of the study, progressive accumulation of activity is demonstrated throughout the peritoneal cavity, outlining bowel loops. The scintigraphic findings are consistent with a biliary leak. The exact site of the biliary leak is difficult to determine, since there is lack of visualization of the intrahepatic biliary ducts and common bile duct.

Note is also made of a linear region of activity with three more discrete areas of tracer uptake just inferior to the right hepatic lobe; this may represent accumulation of activity within the patient's T-tube tract.


The most common indication for hepatobiliary scintigraphy is clinical suspicion of acute calculous or acalculous cholecystitis. In patients who have undergone biliary or hepatic surgery, hepatobiliary scintigraphy may be used to evaluate for evidence of a biloma or an intraperitoneal biliary leak. In these cases, delayed imaging is often useful in making the diagnosis. In the case presented, evidence for an intraperitoneal biliary leak was readily apparent early during imaging and no delayed images were necessary.


The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) following the hepatobiliary study. The ERCP reportedly revealed a leak in the region of the distal bile duct. The leak appeared to be contained and to be distal to the choledochocholedochal anastomosis. A stent was subsequently placed across the choledochocholedochal anastomosis.

ACR Codes and Keywords:

References and General Discussion of Hepatobiliary Scintigraphy (Anatomic field:Gasterointestinal System, Category:Organ specific)

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Case number: hs013

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