A previously healthy 26-year-old male was involved in a motorcycle crash resulting in an American Association for the Surgery of Trauma (AAST) grade IV liver injury confirmed on CT scan (Figure 1A and B). The injury was treated with angioembolization. Following discharge, the patient complained of progressive abdominal fullness and poor appetite. CT scan at three weeks demonstrated a large intrahepatic low attenuation fluid collection with slightly thickened peritoneum and some mass effect on bowel loops (Figure 2A and B).
Contrast-enhanced abdomen CT scan post-trauma showed lacerations in the right hepatic lobe with moderate amount hemoperitoneum.
Follow-up contrast-enhanced CT scan obtained three weeks later demonstrated an extensively large amount of intrahepatic low attenuation fluid collection with slightly thickening peritoneum causing mass effects to bowel loops.
Initial treatment consisted of percutaneous drainage. Because of lack of symptom resolution, the patient underwent exploratory laparotomy 45 days post-injury. This revealed a large bile collection with necrotic liver parenchyma, confirming the diagnosis of posttraumatic intrahepatic biloma.
Non-operative management (NOM) has become the standard of care for most hemodynamically stable blunt liver injured patients, with a reported success rate of more than 80%.Reference Richardson, Franklin and Lukan 1 However, NOM of high-grade liver injuries was associated with significant morbidity. Biloma, biliary fistula, and bile peritonitis are potential complications of bile leakage, and have been seen in 6.4% of patients with blunt liver trauma.Reference Kozar, Moore and Cothren 2 Bilomas occurring after blunt hepatic trauma usually remain asymptomatic and resolve spontaneously. Patients who require additional workup include those with increasing abdominal distension, worsening or persistent abdominal pain, feeding intolerance, or jaundice.
Competing Interests: None declared.
