INTRODUCTION: Bilious effusion is an uncommonly described clinical entity resulting from disruption of the diaphragm as a result of a pleuro-biliary or broncho-biliary fistula. Spillage of bile into the chest cavity causes a spectrum of disease including chemical bronchiolitis, acute lung injury, and necrotizing pneumonia. I describe a case of bilious effusion as a result of a pleuro-biliary fistula.
CASE PRESENTATION: A 66 year-old gentleman with cryptogenic cirrhosis and hepatocellular carcinoma was admitted for evaluation of pneumonia. He presented with two weeks of cough productive of whitish sputum and fatigue with progressive shortness of breath and acute nonpleuritic right-sided chest pain worsened by movement. Of note he denied any fevers, chills, angina, abdominal distension or pain, leg swelling or confusion. On exam he was afebrile, normotensive without evidence of respiratory distress but did require 4 liters per minute (L/min) of oxygen by nasal cannula (NC). His breath sounds were diminished from the right lung base to the mid-lung field with dullness to percussion. His cardiac exam suggested euvolemia. His abdomen was obese but soft without appreciable organomegaly nor ascites and his lower extremities showed no edema. He was without jaundice, petechiae or bruising. He was an able historian and had no asterixis. His initial labs revealed a white cell count of 7800; baseline anemia and mild thrombocytopenia; mild hyponatremia and acute prerenal failure. An arterial blood gas had a pH 7.41, carbon dioxide 26, oxygen 67 on 4 L/min NC. Chest x-ray showed a large right pleural effusion. Thoracentesis yielded turbid, green fluid with a pH 6.78, total cell count of 4221 with 2681 white cells (94% polymorphonucleocytes), lactate dehydrogenase (LDH) 1195 U/L (normal serum LDH <250) and a normal glucose level. Total fluid bilirubin was 18 mg/dL, compared to a serum level of 1.7 mg/dL. He underwent tube thoracostomy for drainage of the exudative effusion. Over a period of ten days he continued to drain over three liters of bilious fluid. He underwent MRCP showing right posterior hepatic lobe biliary tree dilation and erosion of the liver capsule along the border of two liver masses. ERCP was done with balloon dilation, sphincterotomy and stenting of the right biliary tree. Output from the chest tube slowed but the patient's chest x-ray failed to demonstrate full expansion of the right lung. He was therefore taken for pleural decortication with some radiologic improvement. Ultimately he was transitioned to home hospice on Phase 3 oral chemotherapy for his progressive hepatocellular carcinoma.
DISCUSSIONS: Bilious effusion results from change in the normal biliary pressure gradient across a disrupted barrier favored by negative intrathoracic pressure. Historically recognized as a result of hepatic infection or trauma, it is also reported following abdominal surgeries and less invasive procedures causing chemical or thermal injury to the biliary tree. The patient described underwent chemoembolization to his hepatic masses in the six month period prior to this hospitalization; these procedures were notably uncomplicated in the immediate post-intervention period. Unfortunately his hepatocellular carcinoma continued to progress, resulting in the erosion of the liver capsule and fistulization to the pleural space.
CONCLUSION: Bilious effusion is a rare finding recognized in patients with a history of liver disease or injury. Diagnostic measurement of bilirubin in the pleural space or the clinical description of “biliptysis” are hallmarks of this complication. Radiologic confirmation of a damaged diaphragmatic barrier can be made using HIDA scanning or MR imaging. Treatment involves drainage of the pleural space, empiric antibiotics and, failing spontaneous resolution with diversion of biliary flow, can progress to surgical debridement, resection and patching of the diaphragm.
DISCLOSURE: Caroline Motika, None.