A rare case of obstructive shock caused by a giant biloma with right heart compression in a patient undergoing hemodialysis

Abstract

A biloma is a localized bile collection caused by bile leakage that is usually resolved with percutaneous drainage. In most cases, clinical manifestations are limited to local symptoms such as abdominal pain and distension. Although bilomas can occasionally cause septic shock attributable to secondary infection or obstructive jaundice attributable to direct compression of the bile duct, cases involving heart compression by a biloma that leads to circulatory failure have been rarely reported. We report the case of a 79-year-old man undergoing maintenance hemodialysis who developed gallstone-associated cholecystitis complicated by gallbladder perforation that resulted in giant biloma formation that compressed the right heart and caused obstructive shock. At the onset of shock, the patient lacked fever or positive blood culture results, which are typical features of sepsis. The diagnosis of obstructive shock caused by direct compression of the right heart by a giant biloma was determined based on the findings of transthoracic echocardiography (collapsed right heart chambers) and computed tomography (massive fluid collection in the upper abdomen). After removing a large volume of bile using percutaneous transhepatic drainage, blood pressure and cardiac output rapidly improved. When patients undergoing hemodialysis present with unexplained shock and gallstone disease, clinicians should consider extracardiac compression by a giant biloma, promptly evaluate the cardiac and abdominal structures using echocardiography and computed tomography, respectively, and perform early drainage if necessary.

Keywords: Biloma; Hemodialysis; Obstructive shock.