A 58-year-old woman undergoes laparoscopic cholecystectomy for symptomatic gallstones. The operation is recorded as difficult, with dissection in a fibrotic Calot's triangle. On day 5 she re-presents with abdominal pain, anorexia and a temperature of 37.9°C. She is haemodynamically stable. Bloods show WCC 14.2 × 10⁹/L, CRP 156 mg/L, bilirubin 34 µmol/L. CT shows a subhepatic collection with no free air and normal-calibre bile ducts. A percutaneous drain placed by interventional radiology yields 400 mL of bile in 24 hours, and output continues at 250–300 mL/day. What is the most appropriate next step?
- AUrgent laparotomy, washout and repair of the biliary injury
- BMRCP and continued drainage with review in six weeks
- CLaparoscopic washout and clipping of the cystic duct stump
- DERCP with sphincterotomy and biliary stent placement
- EHIDA scan to characterise the leak
Show answer and explanation
Correct answer: D
This is a controlled bile leak in a stable patient — most commonly from the cystic duct stump or a subvesical (Luschka) duct. Once the collection is drained and sepsis is controlled, the priority is to reduce the pressure gradient across the sphincter of Oddi so the leak can close. ERCP with sphincterotomy and stenting achieves this, defines the leak site, and closes low-grade leaks in over 90% of cases; it is both diagnostic and therapeutic.
Why the others are wrong: A — laparotomy is reserved for uncontrolled biliary peritonitis, haemodynamic instability, or a major duct injury requiring reconstruction; operating in a hostile field at day 5 for a controlled leak adds morbidity without benefit. B — MRCP is anatomical, not therapeutic; six weeks of high-volume drainage risks a persistent fistula and sepsis. C — relaparoscopy to clip the stump is unreliable in an inflamed field and does not address the transpapillary pressure gradient. E — HIDA can confirm a leak but adds nothing when bile is already in the drain; it delays definitive treatment.
Key point: a controlled bile leak after cholecystectomy is managed with drainage plus endoscopic decompression of the biliary tree; surgery is for uncontrolled sepsis or major duct injury.
Guidelines: AUGIS and BSG guidance on bile duct injury and post-cholecystectomy bile leak: ERCP with sphincterotomy and stenting is first-line for cystic duct stump and duct-of-Luschka leaks.