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Special Feature
November 15, 2010

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations:Starzl Transplant Institute, University of Pittsburgh Department of Surgery, Pittsburgh, Pennsylvania.



Arch Surg. 2010;145(11):1123. doi:10.1001/archsurg.2010.236-a

A 50-year-old woman who had laparoscopic cholecystectomy for symptomatic cholelithiasis at an outside hospital developed symptoms of abdominal pain, nausea, and vomiting 1 week postoperatively. She initially underwent an abdominal ultrasound, which did not reveal any abnormalities. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) also failed to reveal the cause of her symptoms. An abdominal computed tomographic scan was then performed, which demonstrated a biloma adjacent to the gallbladder fossa. A percutaneous abdominal catheter was placed and drained approximately 400 to 500 mL of bile per day. After a second ERCP was performed, which again failed to delineate a bile leak, the patient was transferred to our institution for further treatment.

On admission to our facility, a repeated ERCP was performed by our institution's gastroenterology service (Figure 1). A hepatobiliary iminodiacetic acid scan showed a persistent biliary leak (Figure 2). She was discharged to home with the abdominal drainage catheter in place to determine if the bile leak would resolve spontaneously. Because the patient continued to drain approximately 500 mL of bile per day at home, she was readmitted 10 days later for further treatment.

Figure 1.
Hepatobiliary iminodiacetic acid scan shows bile leak into gallbladder fossa.

Hepatobiliary iminodiacetic acid scan shows bile leak into gallbladder fossa.

Figure 2.
Endoscopic retrograde cholangiopancreatography read as normal.

Endoscopic retrograde cholangiopancreatography read as normal.

What Is the Diagnosis?

A. Common bile duct injury

B. Transected right posterior hepatic duct

C. Cystic duct leak

D. Duct of Luschka leak