Disorders of the Pleura: Student/Resident Case Report Poster - Disorders of the Pleura |

Loculated Bilothorax: A Rare Sequalae of Obstructive Jaundice Without Biliopleural Fistulization FREE TO VIEW

Adam Austin, MD; Amit Chopra, MD
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Albany Medical College, Albany, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):596A. doi:10.1016/j.chest.2016.08.685
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Pleura

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Bilothorax is an extremely rare cause of pleural effusion, characterized by presence of bile fluid in the pleural space. We report a case of obstructive jaundice leading to bilothorax formation due to inadequate biliary drainage without biliopleural fistulization.

CASE PRESENTATION: A 59 year-old male presented to our medical center with a two-week history of progressive abdominal discomfort, jaundice and unintentional weight loss. The patient was diagnosed with pancreatic adenocarcinoma and a percutaneous drain was placed to alleviate his biliary obstruction. Two weeks into the hospital course, the patient developed new right pleuritic chest pain. A computed tomography of the thorax and abdomen was performed, which demonstrated a right loculated pleural effusion (Figure 1). Bedside ultrasound revealed a complex fluid collection with multiple septations. Pleural fluid analysis exhibited an empyematous bilothorax with a green, cloudy color. The pH was 7.02, total protein ratio 0.71, LDH 1170 IU/L and pleural fluid/serum total bilirubin ratio 1.17 (8.8: 7.5 mg/dL). A hepatobiliary scan did not reveal a biliopleural fistula. The patient was treated with tube thoracostomy for drainage of the loculated pleural effusion along with broad spectrum antibiotics for pleural infection.

DISCUSSION: Bilothorax is an uncommon complication mostly reported after iatrogenic hepatobiliary injury arising from perforation and subsequent biliopleural fistulization. Rarely, bilothoraces can occur from trans-diaphragmatic spread either from diaphragmatic trauma or subphrenic abscess formation (1). In our case, there was no evidence of biliopleural fistulization in the hepatobiliary scan, and therefore the bile leak most likely occurred by passive transit through the diaphragm from a sub-diaphragmatic abscess, via lymphatics in the setting of inadequate biliary drainage, or by caustic damage from bile salts to pleural and peritoneal tissue (2,3).

CONCLUSIONS: Presence of an ipsilateral pleural effusion in association with hepatobiliary injury should raise the suspicion of a bilothorax, and management of the underlying obstruction or injury may resolve this form of effusion.

Reference #1: Cooper AZ, Gupta A, Odom SR. Conservative management of a bilothorax resulting from blunt hepatic trauma. Annals of Thoracic Surgery. 2012; 93: 2043-4.

Reference #2: Basu S, Bhadani S, Shukla VK. A dangerous pleural effusion. Ann R Coll Surg Engl. 2010; 92: 53-4.

Reference #3: Rowe PH. Bilothorax- an unusual problem. J R Soc Med. 1989; 82:687-8.

DISCLOSURE: The following authors have nothing to disclose: Adam Austin, Amit Chopra

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