Subcapsular Biloma Secondary to Gallbladder Perforation in Acute Cholecystitis: A Case Report.

Hepatic subcapsular biloma is a rare complication of gallbladder perforation in acute cholecystitis. We report the case of an 87-year-old man who presented with right upper quadrant pain, a new oxygen requirement, and deranged liver function tests, with a recent history of conservatively managed acute calculous cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a thick-walled gallbladder containing a 2 cm calculus with focal fundal perforation and a large subcapsular fluid collection extending beneath the hepatic capsule, along with an associated right pleural effusion. These findings raised suspicion for gallbladder perforation with subcapsular biloma. Due to worsening inflammatory markers despite antibiotic therapy, the patient underwent ultrasound-guided transhepatic drainage, which confirmed the diagnosis by aspirating bile. One week later, he underwent laparoscopic cholecystectomy with intraoperative cholangiography, which confirmed the perforation site and demonstrated normal biliary anatomy. The patient recovered well; drains were removed sequentially, and he was discharged home with outpatient follow-up. This case highlights that a staged approach combining percutaneous drainage and laparoscopic cholecystectomy is a safe and effective management strategy for gallbladder perforation with subcapsular biloma.