Fig. 1. Abdominal CT scan shows a large biloma in the right abdomen. A locking loop drainage catheter is present within the biloma. Fig. 2. Percutaneous cholangiogram through a 22-gauge needle in the gallbladder. A hole in the distal CBD is seen below the pancreatic duct, with extravasation into a large biloma cavity.

Case Reference No. CC-697-06 A 2-year-old girl suffered blunt trauma to the abdomen as the result of a car accident. On the 5th hospital day she developed right-sided abdominal pain, fever, an elevated white count, and elevated bilirubin. A CT scan of the abdomen showed moderate liver lacerations in the right lobe and a large right abdominal fluid collection with rim enhancement. A 14-F all-purpose drain was inserted into the collection under CT guidance (Fig. 1) and 55 mL of infected bile was aspirated. Following this procedure, the patient improved clinically and her white count and bilirubin normalized. However, the drain continued to put out approximately 400 mL of bile per day for 10 days. An ERCP was attempted but failed because the second portion of the duodenum could not be negotiated. The patient underwent cholangiography via gallbladder puncture with a 22-gauge Chiba needle under ultrasound guidance. This showed a hole in the distal common bile duct (CBD) under the pancreatic duct (Fig. 2) with extravasation into the biloma. The duodenum was not visualized with injection into the mid CBD. The left bile duct was then accessed via an anterior approach and a catheter was positioned in the distal CBD in order to obtain a better cholangiogram (Fig. 3). The distal CBD was then gently probed with a soft Terumo wire. With great difficulty the ampulla was negotiated first with the wire and then with a 5-F catheter which was positioned in the distal duodenum. An 8.5-F biliary drain was introduced with the loop formed in the distal duodenum and side-holes all the way up into the left duct, sealing the distal CBD hole (Fig. 4). Following this procedure, the biloma tube output fell dramatically. Two weeks later a repeat cholangiogram obtained through a vascular sheath with the tip in the mid CBD showed complete healing with normal flow into the duodenum and no extravasation (Fig. 5). A small, straight, capped 5-F catheter was introduced with the tip above the ampulla for safety access. The patient continued doing well and had only scant output from the drainage catheter. One week later all the tubes were removed and the patient was discharged after having been hospitalized for 6 weeks; she had had the biliary drain in for 3 weeks.

Fig. 3. Access into the biliary system was obtained through the left duct. The cholangiogram demonstrates the hole in the distal CBD. The duodenum is not visualized. Fig. 4. A biliary drainage catheter (8.5 F) was introduced into the duodenum, sealing the CBD hole. Fig. 5. Repeat cholangiogram 2 weeks after biliary drainage shows complete healing with normal flow into the duodenum. The duodenal wall appears normal.

Questions 1) What is the best method for percutaneous cholangiography in a baby with a biliary leak (small ducts)? 2) How soon should percutaneous cholangiography be performed in the presence of a large biloma? 3) How long should the biliary drainage catheter be left in place? 4) Are there alternative ways to manage this case?