Unusual Case of Bilio-thorax Reported by Dr. Asad Ali Kerawala and Abid Jamal

Dr. Asad Ali Kerawala and Abid Jamal from the Cancer Foundation Hospital, Karachi, Pakistan recently reported an unusual case of Bilio-thorax, which was an unrecognized complication of liver surgery. The case report has been published in the International Journal of Surgery Case Reports.

Fistulas between the biliary tree and the chest have been a reality after liver surgery. Most of them present as pleural effusions; however, cases of bronchial fistula are also not unheard of. Although a rare complication, Biliothorax, or chole-thorax as it has been called in literature, is a devastating entity if not recognized early. Various causes have been reported for biliothorax, such as:

• Inflammatory
• Abdominal trauma
• Neoplastic
• The most frequent being percutaneous hepatic intervention

Physicians who have a high index of suspicion usually diagnose this before any harm is done, but at times it is diagnosed too late and the patient suffers. Therefore, the authors studied the case of a 60-year-old man who presented for a routine follow-up and reversal of his stoma.

The patient was treated for colon cancer and developed this complication after liver surgery when he reported back after 7 days with dyspnea and fever for 1 day. The patient kept draining 300 mL, 250 mL of bile per day for 7 days. No abdominal collection was found. An ERCP and sphincterotomy were planned, but the sphincter was in spasm and a sphincterotomy could not be performed fully.

The drainage eventually stopped, and the chest tube was removed on the 23rd day. The reason was probably the fact that the bile leak collected and, because of no presence of drain in the abdomen, it made its way into the pleural cavity through the pleuroperitoneal canal. Another cause could be a diaphragmatic injury which was not identified per operatively, but there was no pneumothorax to suggest that, describes Kerawala.

The researchers further discussed that although a rare complication, Biliothorax is a fatal complication if missed. The presence of bile in the pleural cavity is damaging and can lead to empyema, entrapped lung, and even ARDS. Hence, it is imperative to recognize early, find the cause, and treat it appropriately.

They, therefore, concluded that "biliothorax is an under-reported complication of liver surgery which can have disastrous effects on the patient leading to morbidity and even mortality. It is vital to recognize it early and treat accordingly."

For further reference, log in to: https://doi.org/10.1016/j.ijscr.2020.04.080