Photo Quiz

Right Upper Quadrant Pain and Fever After Laparoscopic Cholecystectomy

Am Fam Physician. 2006 Jun 15;73(12):2211-2212.

A 66-year-old man presented with abdominal pain. He had undergone laparoscopic cholecystectomy a week earlier for chronic symptomatic acalculous cholecystitis, and had an uneventful postoperative course. Review of systems revealed fever, nausea, and vomiting for the previous 24 hours. On examination his temperature was 101° F (38.3° C) and there was diffuse abdominal tenderness, predominantly involving the right upper quadrant. His basic metabolic profile, liver function tests, and amylase and lipase levels were within normal limits; his white blood cell count was 17,000 per mm3. Results of abdominal radiography were nonspecific. The results of abdominal computed tomography (CT) are shown in the accompanying figure.

Question

Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?

A. Subcapsular hematoma.

B. Cavernous hemangioma.

C. Subcapsular biloma with biliary peritonitis.

D. Solitary hepatic cyst.

E. Pyogenic hepatic abscess.

Discussion

The answer is C: Subcapsular biloma with biliary peritonitis. CT showed a large sub-capsular hepatic fluid collection, and frank bile was noted on CT-guided aspiration. Cholangiography revealed contrast extravasation from the cystic duct remnant before opacification of the intrahepatic biliary tree, suggesting high-grade bile leak following cholecystectomy.

Biliary leaks complicating laparoscopic cholecystectomy occur with clinical symptoms in up to 4 percent of cases and subclinically in 4 to 7 percent.1 The bile usually courses along the liver surface and into the peritoneum.2 It also may form a biloma.3

Subcapsular hematoma may occur as a result of liver parenchymal injury with bleeding contained by Glisson’s capsule. Blunt liver trauma is the most common cause, but it also may occur as a complication of preeclampsia in pregnancy. The density of the fluid on this patient’s CT scan does not suggest blood.

Cavernous hemangioma is the most common benign hepatic tumor3 and typically is found incidentally on abdominal imaging. CT reveals nodular, isodense peripheral enhancement with large vessels. The lesion usually is less than 5 cm in diameter, located in the right lobe, and asymptomatic. However, lesions larger than 10 cm tend to be symptomatic. Right upper quadrant abdominal pain may result from intra-lesional hemorrhage, localized thrombosis, pressure or distention of Glisson’s capsule, or torsion of a pedunculated hemangioma. Rupture is a rare but serious complication.

Solitary hepatic cysts usually are discovered incidentally. The cyst is found most often in the right hepatic lobe, and only a few of the lesions are larger than 5 cm in diameter. Although lesions often are asymptomatic, patients may experience right upper quadrant abdominal pain. This usually occurs in patients with cysts larger than 5 cm. Intracystic hemorrhage, infection, and neoplasia are potential complications.

The most common etiology for hepatic abscess is biliary tract disease,4 which sometimes can present postoperatively. Fever and right upper quadrant pain are the principal symptoms. Pain usually is constant, of variable intensity, and may exhibit pleuritic features with or without referred pain to the right shoulder if the diaphragm is involved. Nonspecific symptoms, such as weakness, anorexia, nausea, and weight loss, are common. CT with intravenous contrast identifies the abscess as a low-density lesion, often with peripheral enhancement.

Selected Differential Diagnosis of Perihepatic Fluid Collection

Condition Characteristics

Subcapsular hematoma

Occurs as a result of blunt hepatic trauma; blood contained by Glisson’s capsule

Cavernous hemangioma

Common benign hepatic tumor; often incidental finding

Subcapsular biloma with biliary peritonitis

Complication of cholecystectomy; may leak into the peritoneal cavity, causing peritonitis with or without loculate resulting in biloma

Solitary hepatic cyst

Usually noted incidentally during abdominal imaging; complications are rare

Pyogenic hepatic abscess

Fever, right upper quadrant pain, and tenderness; etiology likely biliary tract disease

Selected Differential Diagnosis of Perihepatic Fluid Collection

View Table

Selected Differential Diagnosis of Perihepatic Fluid Collection

Condition Characteristics

Subcapsular hematoma

Occurs as a result of blunt hepatic trauma; blood contained by Glisson’s capsule

Cavernous hemangioma

Common benign hepatic tumor; often incidental finding

Subcapsular biloma with biliary peritonitis

Complication of cholecystectomy; may leak into the peritoneal cavity, causing peritonitis with or without loculate resulting in biloma

Solitary hepatic cyst

Usually noted incidentally during abdominal imaging; complications are rare

Pyogenic hepatic abscess

Fever, right upper quadrant pain, and tenderness; etiology likely biliary tract disease

REFERENCES

1. Dominguez EP, Giammar D, Baumert J, Ruiz O. A prospective study of bile leaks after laparoscopic cholecystectomy for acute cholecystitis. Am Surg. 2006;72:265–8.

2. Lillemoe DL. Biliary injuries and strictures and sclerosing cholangitis. In: Greenfield LJ, Mullholland MW, eds. Greenfield’s Surgery: Scientific Principles and Practice. 4th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins, 2006:1002.

3. Kew MC. Hepatic tumors and cysts. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 7th ed. Philadelphia, Pa.: Saunders, 2002:1592.

4. Zaleznik DF, Kasper DL. Intraabdominal infections and abscesses. In: Kasper DL, Harrison TR, eds. Harrison’s Principles of Internal Medicine. 16th ed. New York, N.Y.: McGraw-Hill, 2005:752.

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