Pthc Collection 265
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In patients with multiple bile leaks or biliary fistulas, percutaneous drainage or nasobiliary drainage should be performed to reduce the size of the collections. In patients with multiple liver abscesses or hepato-biliary malignancies, percutaneous drainage is also indicated. The treatment of a primary biliary fistula includes a combined medical and interventional radiological approach. The use of percutaneous drainage, endoscopic stenting, or transpapillary stenting may be required [20].
The initial diagnosis of a biliary fistula can be made by imagining a communication between the bile duct and the abdominal cavity on an ultrasound and/or CT scan, which may also detect the presence of a stone within the bile duct or bile collection (Figures 1 and 2). This is also the most critical step in the diagnosis and treatment of bile leak or biliary fistula. The next step in the process is the performance of percutaneous ultrasound-guided bile duct puncture, which helps to determine the character of the fistula and its relationship to the extra- or intra-hepatic biliary tree [11, 16]. Finally, the bile leak should be drained using a percutaneous technique [11, 16].
On imaging, bile leaks can be seen as focal extrahepatic fluid collections without bile components or as a dilated intrahepatic duct extending from the leak to the right atrium [15, 18, 19]. The diagnosis of bile leaks and biliary fistulas is usually suspected on the basis of clinical data, with the combined use of abdominal ultrasonography and CT. CT allows confirmation of the leakage with lacerations in the liver, peritoneal fluid collections or fistulas, air in the hepatic cyst or intrahepatic biliary tree, and abnormal bile flow in the afferent limb [18].
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