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BILIARY LEAK
Authored By: drajde01 and Jerold Wallis, Assoc Prof of Radiology.
Patient: 36 year old male
History: 36 year old male: with primary sclerosing cholangitis, 3 days status post orthotopic liver transplant who presents with elevated transaminases. Abdominal sonogram performed a day prior showed a fluid collection in the porta hepatis. There was a clinical concern for biliary leak.
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Fig. 1
First hour of anterior images

Fig. 2
4 hours post injection

Fig. 3
20 hours post injection

Fig. 4
CT
Image Size:[small][as-submitted]

Findings:

Hepatobiliary Scintigraphy:

Findings:  There is delayed accumulation of the tracer by the liver and persistent blood pool activity, consistent with moderately decreased hepatic function.  Delayed images show a loculated collection of activity that develops along the inferior margin of the liver, in the region of the porta hepatis, and correlates with the collection identified on ultrasound.

4-5 hour delayed images show a second loculated collection, which is more linear and may represent pooling of tracer or a small amount of tracer entering the bowel. Obvious flow of tracer into the bowel is not identified.

Additional images were obtained approximately 20 hours after injection of tracer. The small linear focus previously seen immediately inferior to the gallbladder fossa now can be seen to extend further, and is now consistent with excretion of tracer into bowel. Additional bowel activity is also seen.

Impression: 1. Delayed tracer uptake and persistent blood pool activity, consistent with moderate hepatic dysfunction.

2. Loculated collection along the inferior margin of the liver near the porta hepatis, which correlates with the collection seen on ultrasound and is most consistent with a small loculated biloma.

CT Scan:

Impression: 1. Status post recent liver transplant.

2. A 6.6 x 5.4 x 5.4 cm fluid in the gallbladder fossa compatible with the biloma.

DDx:

1.Normal gallbladder (unlikely in this patient s/p cholecystectomy at time of liver transplant).

2.Biloma.

Diagnosis: Biloma due to iatrogenic injury to Duct of Luschka proven after exploratory laparotomy.
General Discussion:

Bild duct injury during laparoscopic cholecystectomy or liver transplantation is produced by either deep dissection or by the injury to the accessory ducts.

The duct of Luschka is an accessory bile duct originating in the right hepatic lobe and drains into the right or common hepatic duct. The frequency of the duct of Luschka in the population ranges from 1% to 50% in the literature.

0.15% of bile leakage occur due to duct of Luschka injury. This is classified into type A biliary leak. Duct of Luschka injury can cause a choleperitoneum, biloma, or subphrenic or subhepatic intraabdominal abscess. Latent clinical symptoms are more common in the duct of Luschka injuries.

Numerous diagnostic methods have been used to detect these injuries, including abdominal ultrasound and computed tomography, endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and hepatic iminodiacetic acid scan.

Exploratory laparotomy is necessary in suspected or proven cases of injury to Duct of Luschka. The surgical treatment includes a lavage of the abdominal cavity, closure of the duct of Luschka, and intraoperative cholangiography to confirm that the biliary tree is intact.

References:

1.Albishri et al; Bile leak from Duct of Luschka after liver transplantaion; Brief communications:Clinical Transplantation;Transplantation:27 July 2001-Vol 72,Issue 2,pg 338-340.

2.J. M. Ramia, PhD, K. Muffak, MD, A. Mansilla, PhD, J. Villar, PhD, D. Garrote, PhD, and J. A. Ferron, PhD; Postlaparoscopic cholecystectomy bile leak secondary to an accessory duct of Luschka. JSLS. 2005 Apr-Jun;9(2):216-7.

3.K. Sharif and J. de Ville de Goyet; Bile Duct of Luschka Leading to Bile Leak After Cholecystectomy—Revisiting the Biliary Anatomy; J Pediatr Surg 38:E60.

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Additional Details:

Case Number: 318486Owner(s): drajde01 and Jerold Wallis, Assoc Prof of RadiologyLast Updated: 02-07-2013
Anatomy: Other   Pathology: Other
Modality: CT, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: bilary leak

Case has been viewed 27 times.
Certified by Jerold Wallis on 06-22-2011

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