A pictorial atlas of post-operative biliary leakage

Learning Objectives To demonstrate the various appearances of biliary leakage which may be encountered on hepatobiliary scintigraphy.

Summary: Biliary leakage is an infrequent but potentially serious complication following surgical instrumentation or manipulation of the hepatobiliary system. In many cases ultrasound and/or CT are the first imaging modalities employed when biliary leakage is suspected. However, in the postoperative patient a fluid collection demonstrated by these anatomic imaging studies is often a nonspecific finding (i.e., could represent hematoma, abscess, etc.). In this setting, hepatobiliary scintigraphy (as a functional imaging modality) plays a very important role in definitive confirmation that such fluid is of biliary origin. In other cases the scintigraphic study may be the first test performed. Regardless, imaging specialists must be aware of the various scintigraphic appearances of biliary leakage. Several cases of biliary leakage detected on hepatobiliary scintigraphy were selected for this educational presentation. The cases demonstrate the variable appearances of biliary leakage and highlight subtleties of HIDA scan interpretation which might affect clinical decision making and patient outcome. Correlation with anatomic imaging (such as ERCP, CT/MRI, ultrasound or, if available, SPECT/CT) can augment diagnostic confidence and help to guide management of biliary leaks.