Non postoperative biloma in Mauritania: case report and literature review

Biloma is used to describe abnormal accumulation of bile outside biliary tract. It is a very rare condition with extrahepatic diffused or encapsulated collection of bile, mostly post-operative or post traumatic. A 72-year-old woman was referred to our hospital with acute abdominal pain located in right upper quadrant. Clinical examination suspected abdominal collection. Imagery (ultrasound and computed tomography scan) demonstrated a large well-defined intra-abdominal collection. Percutaneous ultrasound guided drainage of abdominal collection revealed a bile fluid. Drain was removed a week later and complete resolution of symptoms was obtained in two weeks. Even in the absence of specific diagnostic indications, radiological images may play a key role in the evaluation of suspected biloma in patients with appropriate medical history and clinical characteristics.


Introduction
Biloma is a term used to describe the occurrence of biliary fluid outside the biliary tract. In 1889, there was a [1] reported study of the first case with patient kicked by horse. Eighty years later the word Biloma was introduced by Gould L. [2], who described subject with extra hepatic bile leakage in the upper right quadrant of the abdominal trauma from fighting. Most commonly, bilomas occur in the extra hepatic space with relatively few instances of hepatic subcapsular bilomas. On literature review, bilomas are commonly caused by iatrogenic injury or resulting from abdominal trauma [3,4]. Iatrogenic damage to the biliary system is mostly associated to laparoscopic cholecystectomy [5]. Spontaneous rupture of the biliary tract is reported, and occasionally biloma is rarely observed or being associated [3,5]. Locally chronic inflammation related to detergent bile acids activity causes adhesions, leading to a possible loculated appearance of the collection [4]. The diagnosis is suspected on the basis of the clinical history and usually weeks is required to make the correct diagnosis. In patients it is possible to note clinically; RUQ abdominal pain or distended abdomen, jaundice (choledocholithiasis), peritoneal irritation symptoms or complicated peritonitis with more severe sepsis, [3][4][5][6]. We describe a clinical case managed with percutaneous drainage and review of the literature.

Patient and observation
A 72-year-old female previously healthy, was referred to our teaching hospital suffering from acute abdominal pain located in the right hypochondrium 6 days before. The patient was giving a history

Discussion
It is named biloma any bile collection encapsulated or not in the abdomen, as a consequence of the biliary leak, from biliary tract, mainly of the extrahepatic segment or directly from the canaliculi.
The most common etiology is surgical, endoscopic or traumatic lesions [7]. The literature reports a very low prevalence of fluid biliary collection, and the majority of biloma studies have been based on case reports. Most biloma develops following surgery and abdominal trauma [3,5,8]. As the preference for laparoscopic biliary surgery is increasing, the occurrence of biloma due to iatrogenic perforation increased from 0.1% to 1.5% [4]. During the last 10 years, Sung-Bum et al. [9] reported 11 cases of nontraumatic perforation of the bile ducts. In addition to post-operative and post traumatic injuries, there is also duodenal diverticulum [7] the lost stones in abdominal cavity after a cholecystectomy [10] pancreatic cancer [6] choledochal diverticulum perforation [11] and chronic pancreatitis [9] as etiological factors. It is difficult to determine the etiology of the event, since sometimes it is not possible to identify the site of the lesion. Spontaneous perforation of the bile duct in adults' unrelated to iatrogenic injury or severe trauma is extremely rare and is more often seen in infants and children [12][13][14].
Although the pathophysiology of spontaneous biloma remains to be clarified [15], one study suggested contributing factor is an increased intraductal pressure due to obstructive lesions or infarctions of any part of the biliary tree [16]. The most frequent cause of spontaneous biloma is choledocholithiasis [15,16].
However, several causes of spon¬taneous perforation of bile duct have been seen due to ero¬sion caused by biliary stones that injured the duct wall; increased intraductal pressure due to an Page number not for citation purposes 3 obstruction of the distal bile duct (by stones, carcinomas, or a reflux spasm of the sphinc¬ter of Oddi); thrombosis of a vessel supplying the bile duct wall; intramural infection of the duct as a result of cholangitis; regurgitation of pancreatic secretions into the bile duct; diverticulitis of the bile duct; and acute pancreatitis [17][18][19]. Bilomas are generally localized in the right upper quadrant of the abdomen, neighboring the right hepatic lobe [16]. Our patient presented with