What happens if bile leaks into the abdomen

Bile leaks are usually treated by placing a temporary stent in the bile duct during an ERCP. During an ERCP your doctor places a thin, flexible tube down your esophagus, stomach and the first part of the small bowel to access the bile ducts. Your doctor will then place a stent to help improve the drainage of bile. Your doctor will also give you antibiotics to help prevent infections related to bile fluid that has leaked into your abdominal cavity. Occasionally, surgery may be needed. Enter your starting location or address in the box below to get Google mapped directions to our office location.

They indicate that suspicion should be raised when a patient is not doing well after a cholecystectomy, demonstrating anorexia, abdominal distention suggesting an ileus, and fever.

These findings should raise the surgeon's suspicion and institute appropriate diagnostic studies. I have 3 theoretic disagreements with the authors' evaluation of these patients. I guess I am too old and too simple to have my misconceptions changed. The attempt to separate the presence of bile in the peritoneal cavity into patients who have ascites vs those who have peritonitis seems to me superficial and not worthwhile.

Bile produces a chemical peritonitis associated with cytokine release and alterations in fluid transport across peritoneal membranes, suggesting that an inflammatory process is present. The attempt to designate bile in the peritoneal cavity as representing ascites suggests that it's innocuous, and I don't believe that bile in the peritoneal cavity is innocuous.

Similarly, the attempts by the authors to distinguish bile in the peritoneal cavity as representing ascites from those patients who have peritonitis based on a retrospective analysis of clinical physical findings may not be highly reliable. Second, the terminology of bile ascites and bile peritonitis as emphasized in this article excludes the frequent presentation associated with this problem; namely, a localized collection of bile in the right upper quadrant.

Many patients have a biloma, not bile ascites or bile peritonitis. Lastly, to not correlate the type of injury and treatment from the analysis of the consequences of the presence of bile in the abdominal cavity excludes the 2 factors that in my experience are associated with determining the sequelae of the presence of bile in the peritoneal cavity; namely, is the leak controlled and is the fistula adequately drained?

I have 2 questions for the authors. Could you give us an idea how many patients required drains placed outside of the right upper quadrant? This would suggest to me that if there is seldom an indication to place a drain anywhere besides the right upper quadrant, ultrasound would allow these patients to be treated by percutaneous drainage, obviating the need for a CT scan.

Second, do you feel that serum bilirubin measurements correlate with the quantity of bile in the peritoneal cavity? Dr Lee's presentation was excellent, the article was full of wonderful information to assist surgeons in managing these patients, and I highly recommend it to you. Mitchel P. I wonder if this is a skewed population and if we in practice will not see this rate of bile duct injury as the cause for this problem. In normal practice, the usual cause seems to be liver bed leakage more so than bile duct injury.

In those patients, repeat laparoscopy is such a simple modality that evacuates all of the bile, both in the right upper quadrant and the rest of the abdomen. It avoids the need for interventionalists, both in radiology and gastroenterology. I wonder if you have used this in selected patients.

For instance, if you had operated on a patient and were confident that there was no bile duct injury, would you consider repeat laparoscopy? William W. Turner, Jr, MD, Jackson, Mo: The authors looked at initial drainage at the index operation, but didn't present any conclusions about its efficacy or lack thereof.

I would be interested to know whether they were able to draw any conclusions about the role of index procedure drainage. Thomas A. Stellato, MD, Cleveland, Ohio: I also have a problem with the premise that suggests that a bile collection is equal to a bile duct injury.

We described our own series of patients, and our paradigm is quite different from that of the authors. We feel that a CT scan should not be performed because once a collection is seen, it mandates you to percutaneous drainage. Our first image of choice is a HIDA scan. Our next step would be an ERCP to define whether an injury is present or whether is it a simple leak from a cystic duct or the gallbladder bed.

In that paradigm, we have stented these patients endoscopically and do not have to resort to either reoperation or drainage at all, and all patients have recovered.

Edward H. The earlier a patient is discharged, obviously the more difficult it is to diagnose a bile leak. We tend to keep our patients overnight and find that the patient's heart rate is a key clinical determinant of problem.

No one gets discharged with tachycardia. The tachycardia may not be due to a bile leak, a biloma, or anything serious, but we have found that a normal heart rate usually precludes a significant complication.

So I was wondering whether the vital signs of these patients were looked at both prior to discharge and on follow-up at the clinic. Ronald G. Latimer, MD, Santa Barbara, Calif: What percentage of the patients with their defined bile ascites or bile peritonitis had normal intraoperative cholangiograms? Ernest E. Moore, MD, Denver, Colo: You provide cogent data that indicate that early recognition of the bile collection is critical to minimize the sequellae.

This seems to be a compelling argument for the routine use of surveillance ultrasound by the operating general surgeon in the clinics as well as the office. Could you expand on the shortcomings of ultrasound, because this is certainly not consistent with surgeons' experience with ultrasound in the emergency department. William C. Chapman, MD, Nashville, Tenn: I would like to support the authors' comments regarding imaging and assessment of the patient who is having problems after cholecystectomy.

I think there is a common tendency to attribute symptoms and fluid collections to a trivial leak from the gallbladder fossa and this approach commonly leads to late referral. I think the point that the authors are making is that thorough early investigation is critical to eliminate major bile leakage as a possible factor.

I have a couple of questions. First, could you tell us about the specific complications that occurred in those patients who did have infected bile, and second, what recommendations could you make for management in patients who had drains placed?

Do you follow up for a prolonged interval those patients who do have bile duct injury after drain placement, or do you operate on them early after discovery of the bile duct injury? James J. What prompted you to study these patients? Were they all patients who had drains in place? What percentage had cystic duct leaks or leaks from the accessory duct in the gallbladder fossa and were really just small bilomas?

Dr Way: A main point is that surgeons expect bile in the abdomen to always produce clinical peritonitis, meaning pain and tenderness. Although bile uniformly produces histologic peritonitis, the clinical findings can range from almost no pain to severe pain.

The reason for the differences from patient to patient is unknown. Thus, abdominal pain and tenderness are insensitive criteria for making the diagnosis of bile in the abdomen; for an unpredictable period, pain and tenderness are absent in most patients. In this report we have referred to abdominal bile collections without severe symptoms as bile ascites , regardless of whether the collection was localized or diffuse.

Because there is risk of miscommunication unless words are used in the same way, we defined them precisely in the article. Because the data were collected retrospectively, does this affect the validity of the conclusions?

On the contrary. Retrospective data collection is a positive feature of the study. First, it would probably be impossible to conduct a study like this prospectively, but that is not the point. The advantage of the retrospective aspect is that the analysis is based on statements in the hospital records that preserve the thoughts of those caring for the patients at the moment. The character of these statements would be quite different if collected as part of a prospective study.

In that case, the data would not accurately reflect existing surgical practice. The volume of bile obtained on the initial catheterization varied from about mL to several liters, and the greater the volume, the more likely additional drains would be needed.

The right upper quadrant drained most of the bile. If a second drain was required, it was usually in the pelvis. The serum bilirubin level only loosely correlated with the volume of bile in the abdomen. Bilirubin levels rise because of reabsorption of bilirubin from the abdomen. Our standard treatment for a bile duct leak is an endoscopic retrograde cholangiopancreatography ERCP with placement of a temporary bile duct stent which looks like a plastic straw.

An endoscopic retrograde cholangiopancreatography is a minimally invasive procedure that combines x-ray and upper endoscopy —an exam of the upper gastrointestinal tract, consisting of the esophagus, stomach, and duodenum the first part of the small intestine —using an endoscope, which is a lighted, flexible tube, about the thickness of a finger.

The doctor passes the tube through the mouth and into the stomach, then injects a contrast dye into the ducts to view the bile ducts, which can be seen on x-ray. Special tools can be guided through the endoscope to insert a stent to stop the leak.

To see related medical services we offer, visit our Digestive and Liver Health overview page. To schedule an appointment to discuss your need for bile duct stone treatment, call us at Updated visitor guidelines. Bile Duct Leaks.