Last revised by Jeremy Jones on 28 Jul 2023

Bilomas refer to extrabiliary collections of bile. They can be either intra- or extrahepatic. 

"Biloma" is used variably in the reported literature. Many authors use the term to exclusively refer to intrahepatic bile collections or other bilious collections which are discretely organized. Some authors include free biliary leak into the peritoneum (choleperitoneum: a rarely used term).

Although usually asymptomatic, they may present with symptomatic bile peritonitis 7.

They have many potential causes:

70% of bilomas are localized to the right upper quadrant, whereas the remaining 30% develop in the left upper quadrant. A biloma may wall off or may continue to demonstrate active bile leakage.

The goals of imaging in the assessment of biloma are:

  • confirm the presence of a bile leak

  • determine if it is extrahepatic or intrahepatic

  • describe its extent

  • assess for associated biliary obstruction

Bilious fluid is water attenuation, usually seen collecting in the right upper quadrant. CT intravenous cholangiography can demonstrate a communication between the biliary tree and the biloma, localizing the leak. 

Bilious fluid demonstrates variable signal intensity on T1-weighted imaging, and high signal intensity on T2-weighted imaging, similar to the signal intensity of gallbladder fluid.

Both gadolinium and manganese-based MRI contrast agents that  are excreted through the biliary system are available. A delayed enhanced MRI examination using one of these agents may be useful to confirm that a localized fluid collection is composed of bile and to identify the site of bile leak 7.

Tc99 diisopropyl iminodiacetic acid (DISIDA) scans are useful for confirmation of an active bile leak.

Treatment options include:

  • pigtail drainage (under US/CT guidance)

  • surgical drainage

Management of bilomas can also involve treating any associated biliary tract obstruction which can both complicate and cause bilomas. Surgical repair of the source of underlying biliary tract bile leak may also be required.

General imaging differential considerations include:

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Cases and figures

  • Case 1: post trauma
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  • Case 2: with colonic drainage
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  • Case 3: post traumatic biloma
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  • Case 4: from ruptured gallbladder
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  • Case 5: post cholecystectomy
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  • Case 6: Post-cholecystectomy biloma
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