Biliopleural fistula - A rare complication of blunt thoracoabdominal trauma

Biliopleural fistula - A rare complication of thoracoabdominal trauma ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Biliopleural fistula - A rare complication of blunt thoracoabdominal traumaJ. Abirami Krithiga1*, S. Jeyakumar2, R. Jaivinod3 1PG student, 2Professor, 3Associate ProfessorDepartment of General Surgery, SRM Medical College, Chennai, Tamil Nadu, India*Corresponding author email: [email protected] to cite this article: J. Abirami Krithiga, S. Jeyakumar, R. Jaivinod. Biliopleural fistula - A rarecomplication of blunt thoracoabdominal trauma. IAIM, 2015; 2(3): 179-182.Available online at www.iaimjournal.comReceived on: 17-02-2015 Accepted on: 27-02-2015AbstractWe have reported here a case of thoraco diaphragmatico biliary fistula in a 24 years old male whowas managed conservatively with antibiotics and tube thoracostomy and had complete radiologicalclearance. Thoracobiliary fistulas (TBF) (bronchobiliary and pleurobiliary) are rare complications ofthoraco-abdominal trauma. Owing to their rarity, there is little consensus on the optimalmanagement. The diagnostic suspicion however must be considered and it's important the correctselection of diagnostic imaging techniques.Key wordsThoraco diaphragmatico biliary fistula, Tube thoaracostomy, Biliopleural fistula.Introduction patient had decreased breath sounds on rightThoraco diaphragmatico biliary fistula is a rare side. Chest X-ray showed right side rib fracturesmanifestation of post traumatic complications. involving 3 to 6 and 8 to 11 withGiven their rarity, it is not surprising that there pneumohemothorax, pneumomediastinum andis little consensus on the optimal management extensive surgical emphysema.of these fistulas [1]. Ultrasonography (USG) abdomen showed fluidCase report collection about 200 ml in hepatorenal pouch,A 24 years old male patient with an alleged 100 ml in perisplenic area, 400 ml in bilateralhistory of road traffic accident (RTA) presented paracolic gutter with sings of hemoperitoneumto our hospital with complaints of pain in the with hemorrhagic liver contusion. (Photo – 1)right side of chest and whole of abdomen. After Tube thoracostomy was performed and bloodgetting first aid, he was referred to our hospital was drained. (Photo – 2) Later contrastfor further management. On examination, enhanced tomographic (CECT) scan of chest and abdomen was done which showed right sideInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 179Copy right © 2015, IAIM, All Rights Reserved.

Biliopleural fistula - A rare complication of thoracoabdominal trauma ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)anterolateral displaced fracture from 3rd to 6th Photo - 1: USG abdomen at the level of liver andribs, posterolateral displaced fractures involving kidney showing hemoperitoneum.8 to 11th ribs with pneumohemothorax,pneumomediastinum. Extensive emphysemainvolving bilateral cervical, right anterior, lateralchest wall was present along with perihepaticfree fluid collection, and 6th rib internallydisplaced indenting liver. Grade III liverlaceration involving 5, 6, 7, 8 segment of rightlobe of liver was evident with moderatehemoperitoneum. (Photo – 3) After two days ofthoracostomy, when the blood was drained,brownish colored fluid appeared in the bag withgreenish tinge in intercostals drainage (ICD)tube. (Photo – 4) Thus, the diagnosis of thoraco Photo - 2: Tube thoracostomy.diaphragmatico biliay fistula was made.Biochemical analysis of the ICD fluid was doneand was positive for bilirubin and liver enzymeshence confirmed to be bile. Abdominal signsprogressively improved. To identify biliaryradical injury, MRCP was performed and wasfound to be right lobe posterior segmentalcontusion and laceration with perihepatic andperisplenic hemoperitoneum. (Photo – 5) Focalbiliary dilatation involving the right lobeposterior segmental branches with visual thinstreak of common right hepatic duct (RHD), lefthepatic duct (LHD) and proximal common bile Photo - 3: Right side anterolateral displacedduct (CBD) was present along with biliary injury fracture from 3rd to 6th ribs, posterolateralat the site of liver contusion/ laceration may be displaced fractures involving 8 to 11th ribs withpresent. pneumohemothorax, pneumomediastinum and Grade III liver laceration involving 5, 6, 7, 8ICD drain declined off over the next 2 -3 days. segment of right lobe of liver. (CECT scan)Oral feeds started on 5th day. Diaphragmaticrent cannot be made out by facilities in ourhospital. Biliopleural fistula (BPF) healedspontaneously, patient improved withconservative management. Patient improvedsymptomatically IC drain was removed on 6thday and patient was taken over bycardiothoracic vascular (CTV) surgeons. Patientcame for review after 2 weeks and sent for USGevaluation which was normal.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 180Copy right © 2015, IAIM, All Rights Reserved.

Biliopleural fistula - A rare complication of thoracoabdominal trauma ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Photo - 4: ICD insertion draining fluid was Bronchobiliary fistula may predispose toobserved to have altered colour with the necrotizing bronchitis or bronchopneumonia;greenish tinge over the ICD tube. rarely a chronic indirect pneumonitis may develop [4]. The initial management of patients presenting with thoraco diaphragmatico biliary fistula is conservative management with tube thoracostomy or drainage of sepsis when appropriate, or both; antibiotics are routinely administered [5].Photo - 5: MRCP image shows right lobe Endoscopic cholangiography may demonstrateposterior segmental contusion and laceration the fistulous tract and identify distal biliarywith perihepatic and perisplenic obstruction, which is crucial for the persistencehaemoperitoneum. of TBF. Furthermore, endoscopic sphincterotomy may be undertaken during this study. Endoscopic retrograde cholangiography is advised if symptoms persist to delineate the thoracobiliary communications and undertake sphinteroplasty.Discussion ConclusionEarly diagnosis of BPF is crucial in the Thoraco diaphragmatico biliary fistulas can bemanagement of this condition. A delayed successfully managed using a conservativediagnosis leads to the development of several approach. Surgery should be reserved forcomplications that may warrant extensive persistence of symptoms after exhaustion ofsurgery [2]. Bile has been shown to have a this approach.corrosive effect upon the lung and pleural space.A high index of suspicion in the appropriate Referencesclinical situation is therefore mandatory. Thepresence of bile on thoracocentesis of a pleural 1. Oparah SS, Mandal AK. Traumatic:effusion and bilioptysis are pathognomonic for Thoracobiliary (pleurobiliary andTBF [3]. Bilioptysis may range in presentation bronchobiliary) fistulas: Clinical andfrom bile stained sputum to the expectoration of review study. J Trauma, 1978; 18: 539-large volumes of bile occasionally approaching a 44.liter. Pleurobiliary fistula may predispose to aloculated bilious empyema; the consequent 2. Strange C, Allen ML, Freedland PN,development of pleural adhesions may entrap Cunningham J, Sahn SA. Biliopleuralthe lung, thereby compromising lung function. fistula as a complication of percutaneous biliary drainage: Experimental evidence for pleural inflammation. Am Rev Respir Dis, 1988;International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 181Copy right © 2015, IAIM, All Rights Reserved.

Biliopleural fistula - A rare complication of thoracoabdominal trauma ISSN: 2394-0026 (P)137: 959-61. ISSN: 2394-0034 (O) management. Arch Surg, 1967; 95: 380-3. Porembka DT, Kier A, SchlhorstS, Boyce 6.S, Orlowski JP, Davis K Jr. The 5. Johnson NM, Chin R Jr, Haponik EF.pathophysiologic changes following bile Thoracobiliary fistula. South Med J,aspiration in a porcine lung model. 1996; 89: 335-9.Chest, 1993; 104: 919-24.4. Ferguson TB, Burford TH. Pleurobiliaryand bronchobiliary fistulas: SurgicalSource of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 182Copy right © 2015, IAIM, All Rights Reserved.