The answer
Urgent decompression is required. This is best accomplished by placement
of a drain into the fluid under radiological guidance.
The bile is leaking from the biliary system. The hole may be in the
gallbladder bed due to damage to a minor biliary radical in the liver,
particularly if the gallbladder was embedded in the liver. It may be from an
accessory duct of Luska that connects parts of the right
hepatic biliary system directly to the gallbladder. It may be from the cystic
duct where the clips have come off. Any of these causes of a bile leak will be
aggravated by a distal obstruction in the bile duct, perhaps due to an
unsuspected common bile duct stone.
What the student may say
The acute problem is due to the effects of the large amount of bile that
has accumulated in the peritoneal cavity. This is best dealt with by placement
of a catheter into the collection under radiological guidance. This will
confirm that the fluid is in fact bile and the catheter will then drain the
bile to relieve the effect of the accumulation. Another possibility is that
the fluid is in fact blood, in which case the patient should demonstrate some
of the symptoms and signs of blood loss.
Bile is quite slippy and will leak from even a tiny hole. The common sites
of leakage of bile following cholecystectomy are the gallbladder bed, the
cystic duct and the bile duct. Bile may leak from the gallbladder bed from
damage to a biliary radicle in the bed of the gallbladder or from division of
an accessory duct that leads directly into the gallbladder. The cystic duct
may not have been clipped securely or the clips may have come off. One of the
first manifestations of a major bile duct injury is a bile leak. Any cause of
a bile leak will be aggravated by the presence of a distal obstruction, for
instance an unsuspected common bile duct stone.
I can see from the image that most of the fluid is gone. The inferior vena
cava is much larger now and is almost the same size as the aorta. There is a
linear density seen to the right of the midline anteriorly which probably
represents a drain.
Small print
Urgent laparotomy is not a good idea. The patient is too unwell for major
surgery, there is the opportunity to deal with the acute problem in a less
invasive manner and there is the potential to worsen the situation in the case
of a major duct injury.
Placement of a drain under radiological guidance is the best option in a
sick patient. It will confirm that the fluid is in fact bile and will
decompress the abdomen with little further insult to the patient. Placement
under guidance is safer than blind insertion which has the potential to damage
the intra-abdominal organs.
Laparoscopy and drainage should be considered if the patient is well as it
offers the opportunity to confirm the nature of the fluid, identify the site
of leakage and accurately place a drain down to the site. The gallbladder bed,
the cystic duct etc can all be inspected safely. However in a sick patient it
is better to place the drain percutaneously under radiological guidance.
Immediate transfer to a tertiary referral centre is probably not a good
idea in a sick patient if it is possible to place a drain safely under
radiological guidance locally. Transportation of a sick patient is risky,
particularly if the patients condition can be easily improved prior to
transfer.
The bile may be leaking from anywhere but the main causes are;
- The gallbladder bed, either from an accesssory duct of Luska or
from a biliary radical that has been divided in the gallbladder bed.
- The cystic duct, because the clips are not securing it fully, for
instance the clips were too small for the duct, or the clips have fallen off.
- The bile duct has been injured and is leaking bile.
It is wise to reflect that any of these causes of leakage is aggravated by
a distal obstruction, perhaps there is an unsuspected gall stone in the common
bile duct.
