Case Report

A 71-year-old man with a 3-year history of calculous cholecystitis was referred for upper gastrointestinal endoscopy due to increasing upper abdominal pain, nausea and intermittent vomiting for the past few weeks. He had no fever and liver function tests were normal. Gastroscopy showed a large circumscribed abutment of the gastric antrum suggesting a subepithelial lesion (Fig. 1). 

Figure 1. Gastroscopy: large circumscribed abutment of the gastric antrum suggesting a subepithelial lesion.

Endoscopic ultrasound was performed for additional characterization and documented a scleroatrophic gallbladder with stones and a large collection, extrinsic to the gastric wall – abutting the anterior wall of the gastric antrum, with anechoic content and several calcifications (with shadowing) suggestive of stones (Fig. 2).

Figure 2. EUS (transgastric view): large collection, extrinsic to the gastric wall, with anechoic content and several calcifications (with shadowing) suggestive of stones.


Quiz

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Discussion

Endoscopic ultrasound favored an organized collection of bile (biloma) and MR/MRCP confirmed a perigastric 65x40x45mm collection, filled with fluid and several gallstones, contiguous to a scleroatrophic gallbladder (Fig. 3). 

Figure 3. MR/MRCP: perigastric 65x40x45mm collection, filled with fluid and several gallstones, contiguous to a scleroatrophic gallbladder.

The patient underwent an open cholecystectomy, with marsupialization and drainage of the perigastric biloma. No intraoperative evidence of gallbladder perforation was noted and the patient had a favorable outcome. 

Biloma is defined as an encapsulated collection of bile (which may also contain sludge and gallstones) outside the biliary tree. Most cases are either iatrogenic (following cholecystectomy) or traumatic. Rare cases of spontaneous biloma as a complication of acute cholecystitis, choledocholithiasis and cholangiocarcinoma have also been reported [1,2]. The proposed mechanism is raised intravesicular or intraductal pressure, caused by obstruction (from a gallstone or a tumor), leading to bile leakage [3]. We report a case of a spontaneous biloma as a complication of cholecystitis, with an insidious presentation, mimicking a subepithelial gastric lesion.  


References

  1. Liu W, Wang S, Guo J, et al. A rare case of a biloma mimicking a submucosal tumor arising from the lower esophagus [published online ahead of print, 2020 Oct 8]. Endoscopy. 2020;10.1055/a-1244-9393.
  2. Rizvi BS, Rajkumar A. Spontaneous Biloma: A Rare Complication of Acute Cholecystitis. Am J Gastroenterol. 2015;110(Supplement 1):S92.
  3. Ji G, Zhu F, Wang K, Jiao C, Shao Z, Li X. A giant and insidious subphrenic biloma formation due to gallbladder perforation mimicking biliary cystic tumor: A case report. Mol Clin Oncol. 2017;6(1):71-74. 


Authors

Miguel Bispo1, Susana Marques1, Sara Teles Campos1, Ricardo Rio-Tinto1, Paulo Fidalgo1, Vera Oliveira2, Gil Gonçalves2, Jacques Devière1,3

  1. Department of Gastroenterology and Digestive Endoscopy, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal
  2. Department of Surgery, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal
  3. Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital – Université Libre de Bruxelles, Brussels, Belgium