Synopsis
Recognise bile-duct injury and leakage after upper abdominal surgery, stabilise sepsis, define anatomy without harmful delay, and refer early to an HPB reconstruction team.
- Suspect injury when recovery after cholecystectomy is unexpectedly painful, tachycardic, febrile, jaundiced or accompanied by bile in a drain or wound.
- Begin with physiology, blood tests and ultrasound or CT to identify collections and duct dilatation; a normal wound does not exclude internal bile.
- Drain infected or symptomatic collections promptly, send fluid for bilirubin and microbiology, and start intravenous antibiotics within one hour when biloma or bile peritonitis causes severe sepsis or shock.
Key red flags
Bile peritonitis, shock or a rapidly enlarging collection requires urgent drainage and critical-care support.
Early jaundice with little drain output can indicate major duct occlusion or transection rather than a harmless postoperative liver-test fluctuation.
Pain, distension, ileus, fever and tachycardia with no external bile may indicate an enlarging biloma or bile peritonitis.
Investigation priorities
Identify cholestasis, infection and organ dysfunction.
Management branches
Four days after laparoscopic cholecystectomy, a patient is febrile and tachycardic with right-upper-quadrant pain; CT shows a large perihepatic collection.
- Assess NEWS2 and hypoperfusion, obtain cultures, and start broad-spectrum intravenous antibiotics within one hour if high risk. If fluid is required under NG253, give 250 mL balanced crystalloid over 10–15 minutes, reassess after each bolus, and repeat only if needed up to 1,000 mL while arranging image-guided drainage.
- Test and observe drain fluid, review the operation note and clips, and obtain specialist biliary imaging to determine whether duct continuity is preserved.
Key medicines
Co-amoxiclav for postoperative intra-abdominal infection: current DBTH adult exampleFor an adult covered by the Doncaster and Bassetlaw Teaching Hospitals September 2025 postoperative intra-abdominal infection protocol, give co-amoxiclav 1.2 g intravenously every 8 hours. Review oral switch at 48–72 hours and, if improving with reliable absorption, use 625 mg orally every 8 hours; DBTH uses 5 days according to response, while WSES advises considering 5–7 days for biloma or generalised biliary peritonitis, so set the stop after drainage, cultures and clinical response. Under the same DBTH postoperative intra-abdominal infection protocol, if the patient is older than 65 years AND received co-amoxiclav or a cephalosporin in the preceding 2 weeks, use piperacillin/tazobactam 4 g/0.5 g (4.5 g) by intravenous infusion every 8 hours instead, then de-escalate to an appropriate oral antibiotic from cultures or Infection Team advice; the protocolled total course is 5 days according to clinical response and source control.Avoid after serious penicillin or beta-lactam hypersensitivity and after co-amoxiclav-associated jaundice or hepatic dysfunction. Check renal function: the current intravenous SmPC uses an initial 1,000/200 mg then 500/100 mg every 12 hours for creatinine clearance 10–30 mL/min, or every 24 hours below 10 mL/min. Seek infection and pharmacy advice for allergy, resistant organisms, organ failure or prior biliary instrumentation, and narrow to blood or bile cultures. For piperacillin/tazobactam, the current SmPC specifies infusion over 30 minutes, no renal change above 40 mL/min, 4 g/0.5 g every 8 hours as the maximum at creatinine clearance 20–40 mL/min, and 4 g/0.5 g every 12 hours below 20 mL/min. Avoid it after penicillin hypersensitivity or a severe immediate reaction to another beta-lactam.