Postcholecystectomy abdominal bile collections

Hypothesis: The clinical syndromes caused by bile collections in the abdome n span a wide spectrum and their natural history and risks are not fully ap preciated. Design: Analysis of 179 patients with bile fistulas after cholecystectomy, of which 154 patients had undrained bile collections. Objective: To characterize the manifestations and natural history of abdomi nal bile collections. Setting: A tertiary care teaching hospital. Patients and Methods: The clinical findings in 179 patients with bile fistu las resulting from iatrogenic laparoscopic bile duct injuries and other mis cellaneous operations between 1990 and 1999 were analyzed. The group of mai n interest consisted of 154 patients with undrained bile collections. Of th ese 154 patients, 21% had serious complications, including sepsis and multi organ failure. The data were analyzed to identify the variables associated with this undesirable outcome. Main Outcome Measures: Symptoms, physical findings, course of illness, and laboratory and imaging findings. Results: The clinical manifestations of intra-abdominal bile collections we re initially discounted in 77% of patients, so the problem went unsuspected for a variable and often lengthy period. Abdominal pain and tenderness (bi le peritonitis) gradually developed in 18% of patients with bile ascites. T here were no differences in the initial clinical findings in this group com pared with these who did not develop peritonitis. Nineteen percent of patie nts with undrained bile collections experienced serious morbidity. The init ial clinical findings did not differ in these patients compared with those with a less complicated illness. Serious illness, however, was associated w ith the following: (1) a longer period of undrained bile (15.4 vs 9.2 days, P=.04) and (2) a higher incidence of infected bile (45% vs 7%, P=.001). Conclusions: (1) Prominent abdominal pain and tenderness developed in only 21% of patients with abdominal bile collections; (2) the symptoms caused by bile collections were often subtle and their significance was overlooked, which resulted in a delay in diagnosis; (3) the early clinical findings cou ld not distinguish patients who did become critically ill from those who di d not; and (4) seriously ill patients more often had delayed drainage and i nfected bile. Still, failure to drain a bile collection within just 5 days resulted in serious illness in a few patients. Surgeons must watch for the clinical manifestations of bile ascites after laparoscopic cholecystectomy. This diagnosis should be suspected whenever persistent bloating and anorex ia last for more than a few days; failure to recover as smoothly as expecte d is the most common early symptom of bile ascites. If bile collections wer e promptly diagnosed and drained, the rate of serious illness resulting fro m this complication would decline.