S3407 Infected Biloma in the Gallbladder Fossa: A Rare Post-Cholecystectomy Complication

Introduction: Laparoscopic cholecystectomy is the standard approach for treating acute cholecystitis due to improved patient outcomes, shorter hospital stays, and reduced re-hospitalizations. However, it carries a higher risk of iatrogenic biliary injuries (0.3%–0.6%) compared to open cholecystectomy (0.1%). Such injuries can result in rare complications like biloma formation. We present a rare case of an infected post-cholecystectomy biloma within the gallbladder fossa, complicated by secondary sclerosing cholangitis. Case Description/Methods: Sixty-nine-year-old man with complex medical history, including emphysematous cholecystitis status post laparoscopic cholecystectomy complicated by cholangitis requiring stents, drainage and antibiotics, presented with fatigue, hypotension, and abdominal tenderness. Computed tomography abdomen and magnetic resonance cholangiopancreatography (MRCP) revealed a loculated collection with well-defined thin margins in the gallbladder fossa. Endoscopic retrograde cholangiopancreatography (ERCP) ruled out a biliary leak but revealed new, diffuse biliary tract stenosis consistent with secondary sclerosing cholangitis. Aspiration of 60 mL of bilious fluid from the fossa grew vancomycin resistant (VRE) Enterococcus faecium and extended spectrum beta lactamase (ESBL) Klebsiella; He was started on meropenem and linezolid. However, the bilious fluid re-accumulated within 48 hours despite no identifiable leak. Subsequently, an intra-hepatic drain was placed. Unfortunately, his course was complicated by acute stress cardiomyopathy, ultimately leading to demise. Discussion: This case reflects on numerous pertinent factors. First, early diagnostic imaging is essential in differentiating bilomas from other fluid collections, such as seromas and abscesses, given the higher risk of mortality especially when infected. However, radiographic appearance is insufficient and direct fluid sampling aids in confirming diagnosis. Second, while ERCP and radionuclide imaging occasionally identify the site of leaks, in many cases, as in ours, the source remains elusive. Therefore, clinical judgment should prioritize timely intervention over definitive localization. Third, infected bilomas require aggressive multidisciplinary management with percutaneous drainage and targeted antibiotics to prevent complications like peritonitis or bilhemia. In summary, infected bilomas, though uncommon, require vigilant monitoring and decisive action to ensure favorable patient outcomes.