Imaging: Student/Resident Case Report Poster - Imaging |

A Clever Method to Diagnose Acquired Bronchobiliary Fistula FREE TO VIEW

Steve Tseng, DO; Seth Assar, MD; Nikita Chand, MBBS; Ashwani Gore, MD; Da Wei Liao, MD
Author and Funding Information

Banner -- University Medical Center Phoenix, Phoenix, AZ

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

Chest. 2016;150(4_S):670A. doi:10.1016/j.chest.2016.08.764
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SESSION TITLE: Student/Resident Case Report Poster - Imaging

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: Biliptysis, the presence of bile in the sputum, is a known but rare complication of biliary stenosis, tumor, trauma and or surgery. This distinctive clinical finding is pathognomonic for bronchobiliary fistula (BBF).

CASE PRESENTATION: A 77 year-old female presented to the emergency room with persistent shortness of breath and cough productive of green sputum. She has a history of Hepatitis C-related hepatocellular carcinoma (HCC) and had underwent radiofrequency ablation (RFA) followed by wedge resection years prior to admission. After experiencing HCC recurrence, she underwent a transarterial chemoembolization (TACE) with Yttrium-90 (Y90) and adjunctive RFA. Of note, she was treated in the preceding two weeks for community-acquired pneumonia without improvement in symptoms. Concern for delayed healthcare-associated pneumonia prompted expanded antibiotic therapy. Despite several days of therapy she failed to improve which prompted further work-up. During bronchoscopy copious bright green-tinged sputum was found originating from the right lower lobe. Bronchoalveolar lavage was culture negative for pathogenic microbes, but urine dipstick confirmed the presence of bile. A hepatobiliary iminodiacetic acid (HIDA) scan confirmed fistulization of the right lobe of the liver with the right lower lobe of the lung. Ultimately, she underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. Despite the ERCP, she had no change in the quality or quantity of bilious sputum produced. Her fistula was ultimately sealed with a microvascular plug and multiple interlocking detachable coil embolizations to the fistula followed by repeat cyanoacrylate / ethiodized oil glue sealing.

DISCUSSION: BBF is a rare complication of primarily hepatobiliary tree tumors and biliary obstruction, but trauma and infectious etiologies have also been reported. Sixty-eight cases have only been reported in literature review of 1980-2010. Management is often multi-modal and directed at the underlying etiology. We highlight a unique case illustrating an association between intervention and the complication of BBF. In our case, it was likely that her multiple interventions aimed at her HCC altered the anatomy and ultimately contributed to the development of her acquired BBF. With increased frequency of minimally-invasive treatment modalities directed at HCC, the incidence of BBF may increase and should be considered. Thus, in such a group of patients, green-productive sputum may indicate signs to a more serious underlying pathology such as BBF.

CONCLUSIONS: Biliptysis is a noteworthy physical finding of an uncommon etiology which often requires complex and individualized management.

Reference #1: Liao GQ, Wang H, Zhu GY, Zhu KB, Lv FX, Tai S. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World J Gastroenterol 2011 September 7; 17(33): 3842-3849

DISCLOSURE: The following authors have nothing to disclose: Steve Tseng, Seth Assar, Nikita Chand, Ashwani Gore, Da Wei Liao

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