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Mon, 7 Jan 2002 22:17:41 -0800 (PST)

I have a 22 year old male patient who was referred to
our facility after sustaining 2 GSWs to the back. He
was initially admitted to a remote provincial hospital
where he reportedly underwent laparotomy for repair of
multiple intestinal perforations. He was subsequently
transferred to our facility 33 hours post-injury.

On admission he was stable, normotensive, afebrile. He
had 2 GSWs at the back, one at level L1 left mid
scapular line, and another at level T10 right
posterior axillary line. Anteriorly he had a sutured
midline laparotomy incision and there was a GSW of
exit in the epigastrium, just to the right of the
midline from which was oozing brownish fluid (bile).
The abdomen was flat, soft, with slight tenderness on
palpation around the incision, otherwise, everything
was unremarkable. 2 days later, he was still afebrile,
the abdomen was soft and non-tender, and he was
hungry. The output from the GSW of exit was 700 cc.
Suspecting a biliary-cutaneous fistula a soft Fr 10
rubber catheter was inserted into the cutaneous
opening and a fistulogram was done. This revealed
opacification of the gall bladder and intra hepatic
ducts. There was no spillage of contrast into the
peritoneal cavity. Patient is now on his 5th day in
our hospital, he is feeding, has passed flatus and
stools, and remained afebrile. No abdominal
complaints, no jaundice. Fistula output is 750 to 900
cc bile per day. We plan to operate on him to try to
locate the source of the bile leak.

Is there room for non-operative management in this
case? Any opinion from the list will be appreciated.

Dr. Jun Pangilinan
Baguio General Hospital
Baguio City, Philippines 

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bile fistula