Pulmonary Vascular Disease: Rare Pulmonary Disorders |

Cholethorax: An Unusual Cause of Pleural Effusion With an Unusual Etiology FREE TO VIEW

Jay Patel, MD; Vanthanh Ly, MD
Author and Funding Information

New York Harbor Healthcare Systems, Veterans Affairs, Brooklyn, NY

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

Chest. 2016;150(4_S):1199A. doi:10.1016/j.chest.2016.08.1308
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SESSION TITLE: Rare Pulmonary Disorders

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Monday, October 24, 2016 at 11:00 AM - 12:00 PM

INTRODUCTION: Cholethorax is a rare cause of pleural effusion but is a well documented complication of biliary manipulation. The mechanism behind this has always been documented as a biliary-pleural fistula. We describe a new etiology utilizing a transdiaphragmatic biliary gradient to support our claim.

CASE PRESENTATION: A 66 year old man was admitted to the ICU for sepsis in the setting of abdominal pain and distension 1 day post cholecystectomy. He initially presented 2 months prior with cholecystitis and was successfully treated with antibiotics and a cholecystostomy tube. In the ICU he was treated with antibiotics and peritoneal drainage (bilirubin level of 49.5) after work up showed suprahepatic fluid collection. He was persistently febrile with ongoing output from peritoneal drain and developed worsening right pleural effusion. Thoracocentesis showed sterile exudative effusion with bilirubin of 3.1. Endoscopy with cholangiogram showed cystic duct bile leak, and a stent was placed shunting bile from the hepatic ducts to the common bile duct, bypassing the cystic duct. The patient’s abdominal distension improved soon afterward. He defervesced and imaging showed resolution of pleural effusion.

DISCUSSION: Cholethorax is a rare cause of pleural effusion, etiology has been described as biliary-pleural fistula however we describe a new etiology secondary to hepatic hydrothorax.1 Hepatic hydrothorax is caused by diaphragmatic defects and abdominal positive pressure. Management is conservative with diuretics and salt restriction. Cholethorax secondary to biliary pleural fistula is a dangerous clinical entity. Management involves rapid decompression of the pleural space along with ERCP and possible surgical decompression.2 In our patient hepatic hydrothorax was supported by temporal sequence of events and multiple imaging studies. We argue that the gradient of bilirubin between the ascites fluid and pleural fluid can be used to differentiate a biliary pleural fistula from hepatic hyrdothorax; results would be a low and a high gradient respctively. Our patient had a pleural fluid bilirubin level of 3.1 mg/dL and an ascitic fluid bilirubin level of 49.5 mg/dL; a high ascites-pleural fluid bilirubin gradient arguing against a fistula and more likely a hepatic hydrothorax.

CONCLUSIONS: Any patient with pleural effusion and ascites with suspicion of a biliary pathology should have bile levels of ascites and pleural fluid checked along with other routine tests. We propose that a simple ascites-pleural biliary gradient can be a relatively low risk and cost efficient tool to guide management of cholethorax. Surgical approaches including VATS can be avoided in this case and a conservative approach with ERCP and bypass of biliary leak can be pursued. Future cases should be reported so a comparison can be made to validate our findings.

Reference #1: Richard W. Light. Pleural Diseases. Lippincott, 2007

Reference #2: Crnjac. Thoracobiliary fistulas: literature review and a case report. Rad Onc. Mar 2013

DISCLOSURE: The following authors have nothing to disclose: Jay Patel, Vanthanh Ly

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