Case Report
Broncho-hepatico-cutaneous fistula in a case of amoebic liver abscess
Tropical Doctor 2014, Vol. 44(2) 110–111 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513518529 tdo.sagepub.com
Navneet Kaur1, Kavish Maheshwari2 and Arun Gupta1
Abstract Pulmonary complications occur in 7–20% of patients with amoebic liver abscess(ALA) and may present as pleural effusion, empyema, lung abscess or a bronchohepatic fistula. Rupture into a bronchus presents as sudden coughing with expectoration of chocolate-coloured sputum and is usually managed by postural drainage, bronchodilators and antiamoebic drugs. A young boy presented with a large amoebic liver abscess of about 1 L volume which ruptured into the lung. He required surgical drainage of the liver abscess as even after intubation he was not able to maintain adequate ventilation. Following this he developed a broncho-hepatico-cutaneous fistula with drainage of 400–500 mL bile per day and bubbling of air in the abdominal drain. He underwent selective right hepatic duct cannulation with endo-papillotomy, following which the fistula closed gradually.
Keywords Amoebic liver abscess, pulmonary complications, bronchohepatic fistula
Introduction Pulmonary complications occur in 7–20% of patients with amoebic liver abscess (ALA).1 A symptomatic right-sided pleural effusion is the most common pulmonary complication and usually does not require a treatment itself. Other complications include rupture of the abscess into the pleural cavity, bronchial tree or development of a lung abscess. Rupture into the pleural space manifests itself as dyspnoea and dry cough with right basal crepitations and collapse of the right lung. Rupture into the bronchi presents as sudden onset of coughing with expectoration of copious quantities of chocolate-coloured sputum.2 Surgical intervention is usually not required as postural drainage, bronchodilators and anti-amoebic drugs suffice. We present here an interesting case of ALA which required surgical intervention for bronchial rupture and subsequently developed an air leak in the abdominal drain.
Case report A 16-year-old boy presented with fever and pain in the right upper abdomen for 15 days and progressive abdominal distention for 10 days. On examination the liver was grossly enlarged and tender but there were no signs of peritonitis. There was diminished air entry in the right lung basal region. On investigation his
haemoglobin was 8.7 gm%, TLC 19,000/mm,3 platelet count 90,000/mm3 and INR of 1.68. Serum bilirubin was normal. An ultrasound and CT scan revealed a liver abscess of 1000 cc in the right lobe with presence of gas and mild free fluid abdomen (Figures 1 and 2). He was managed as a case of liver abscess with sepsis with coagulopathy and received intravenous antibiotics, transfusions of red cell concentrate and fresh frozen plasma. An ultrasound-guided aspiration of the abscess cavity was also done but the presence of gas masked entry into the abscess cavity and only 200 mL of pus was aspirated. Pus culture grew Escherichia coli. The serology for entamoeba was positive, and a diagnosis of amoebic liver abscess with secondary bacterial infection was made. After initial improvement, on the fifth day the patient developed breathlessness with a cough and expectoration of rusty-coloured sputum with rapid deterioration of vitals. On chest X-ray, bilateral costo-phrenic angles were clear with raised dome of 1 Professor, Department of Surgery, UCMS & GTB Hospital, University of Delhi, Delhi, India 2 Postgraduate Student in Surgery, Department of Surgery, UCMS & GTB Hospital, University of Delhi, Delhi, India
Corresponding author: Navneet Kaur, Professor, 407 Gagan Vihar, Delhi 110051, India. Email: [email protected]
Downloaded from tdo.sagepub.com at Gazi University on May 7, 2015
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Figure 2. Amoebic liver abscess with presence of gas in the abscess cavity.
Figure 1. Amoebic liver abscess with presence of gas in the abscess cavity.
diaphragm. He required endotracheal intubation for falling blood oxygen saturation and laparotomy was performed to drain liver abscess. A drain in the abscess cavity and an intercostal chest tube drain were placed. In the postoperative period, bubbling of air was seen in the abdominal drain suggestive of an iatrogenic broncho-hepatico-cutaneous fistula. The air leak, however, stopped spontaneously after 4 days. There was also persistent drainage of 400–500 mL bile per day. An endoscopic retrograde cholangiopancretography (ERCP) showed a leak from the right hepatic ductal system. A selective right duct cannulation with endopapillotomy was done. Drain output progressively decreased and it was removed on the 10th day. An ultrasound 3 weeks later showed a residual cavity of 60 cc.
Discussion No defined algorithm exists for the management of pulmonary rupture of ALA and a conservative approach is usually recommended.2 However, in our case shear volume of the pus filling up airways mandated a more
effective surgical drainage which led to development of broncho-hepatico-cutaneous fistula followed by a high output biliary fistula. ERCP and stenting of the biliary tree is an accepted protocol for the management of bronchobiliary fistulas and persistent leaks after liver surgery; and this also cured our patient.3,4 Another interesting finding was the presence of gas in the abscess cavity due to which effective aspiration of the abscess could not be accomplished. This gas probably reached the abscess through some microcommunication with pulmonary parenchyma before it eroded into the bronchial tree. Gas in ALA may be taken as a warning sign of an impending pulmonary rupture. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Stanley SL Jr. Amoebiasis. Lancet 2003; 361: 1025–1034. 2. Shamsuzzaman SM and Hashiguchi Y. Thoracic amebiasis. Clin Chest Med 2002; 23: 479–492. 3. Liao GQ, Wang H, Zhu GY, Zhu KB, Lv FX and Tai S. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World J Gastroenterol 2011; 17: 3842–3849. 4. Gandini R, Konda D, Tisone G, Pipitone V, Aneslmo A and Simonetti G. Bronchobiliary fistula treated by self expanding ePTFE- covered nitinol stent-graft. Cardiovasc Intervent Radiol 2005; 28: 828–831.
Downloaded from tdo.sagepub.com at Gazi University on May 7, 2015
Broncho-hepatico-cutaneous fistula in a case of amoebic liver abscess
Tropical Doctor 2014, Vol. 44(2) 110–111 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513518529 tdo.sagepub.com
Navneet Kaur1, Kavish Maheshwari2 and Arun Gupta1
Abstract Pulmonary complications occur in 7–20% of patients with amoebic liver abscess(ALA) and may present as pleural effusion, empyema, lung abscess or a bronchohepatic fistula. Rupture into a bronchus presents as sudden coughing with expectoration of chocolate-coloured sputum and is usually managed by postural drainage, bronchodilators and antiamoebic drugs. A young boy presented with a large amoebic liver abscess of about 1 L volume which ruptured into the lung. He required surgical drainage of the liver abscess as even after intubation he was not able to maintain adequate ventilation. Following this he developed a broncho-hepatico-cutaneous fistula with drainage of 400–500 mL bile per day and bubbling of air in the abdominal drain. He underwent selective right hepatic duct cannulation with endo-papillotomy, following which the fistula closed gradually.
Keywords Amoebic liver abscess, pulmonary complications, bronchohepatic fistula
Introduction Pulmonary complications occur in 7–20% of patients with amoebic liver abscess (ALA).1 A symptomatic right-sided pleural effusion is the most common pulmonary complication and usually does not require a treatment itself. Other complications include rupture of the abscess into the pleural cavity, bronchial tree or development of a lung abscess. Rupture into the pleural space manifests itself as dyspnoea and dry cough with right basal crepitations and collapse of the right lung. Rupture into the bronchi presents as sudden onset of coughing with expectoration of copious quantities of chocolate-coloured sputum.2 Surgical intervention is usually not required as postural drainage, bronchodilators and anti-amoebic drugs suffice. We present here an interesting case of ALA which required surgical intervention for bronchial rupture and subsequently developed an air leak in the abdominal drain.
Case report A 16-year-old boy presented with fever and pain in the right upper abdomen for 15 days and progressive abdominal distention for 10 days. On examination the liver was grossly enlarged and tender but there were no signs of peritonitis. There was diminished air entry in the right lung basal region. On investigation his
haemoglobin was 8.7 gm%, TLC 19,000/mm,3 platelet count 90,000/mm3 and INR of 1.68. Serum bilirubin was normal. An ultrasound and CT scan revealed a liver abscess of 1000 cc in the right lobe with presence of gas and mild free fluid abdomen (Figures 1 and 2). He was managed as a case of liver abscess with sepsis with coagulopathy and received intravenous antibiotics, transfusions of red cell concentrate and fresh frozen plasma. An ultrasound-guided aspiration of the abscess cavity was also done but the presence of gas masked entry into the abscess cavity and only 200 mL of pus was aspirated. Pus culture grew Escherichia coli. The serology for entamoeba was positive, and a diagnosis of amoebic liver abscess with secondary bacterial infection was made. After initial improvement, on the fifth day the patient developed breathlessness with a cough and expectoration of rusty-coloured sputum with rapid deterioration of vitals. On chest X-ray, bilateral costo-phrenic angles were clear with raised dome of 1 Professor, Department of Surgery, UCMS & GTB Hospital, University of Delhi, Delhi, India 2 Postgraduate Student in Surgery, Department of Surgery, UCMS & GTB Hospital, University of Delhi, Delhi, India
Corresponding author: Navneet Kaur, Professor, 407 Gagan Vihar, Delhi 110051, India. Email: [email protected]
Downloaded from tdo.sagepub.com at Gazi University on May 7, 2015
Kaur et al.
111
Figure 2. Amoebic liver abscess with presence of gas in the abscess cavity.
Figure 1. Amoebic liver abscess with presence of gas in the abscess cavity.
diaphragm. He required endotracheal intubation for falling blood oxygen saturation and laparotomy was performed to drain liver abscess. A drain in the abscess cavity and an intercostal chest tube drain were placed. In the postoperative period, bubbling of air was seen in the abdominal drain suggestive of an iatrogenic broncho-hepatico-cutaneous fistula. The air leak, however, stopped spontaneously after 4 days. There was also persistent drainage of 400–500 mL bile per day. An endoscopic retrograde cholangiopancretography (ERCP) showed a leak from the right hepatic ductal system. A selective right duct cannulation with endopapillotomy was done. Drain output progressively decreased and it was removed on the 10th day. An ultrasound 3 weeks later showed a residual cavity of 60 cc.
Discussion No defined algorithm exists for the management of pulmonary rupture of ALA and a conservative approach is usually recommended.2 However, in our case shear volume of the pus filling up airways mandated a more
effective surgical drainage which led to development of broncho-hepatico-cutaneous fistula followed by a high output biliary fistula. ERCP and stenting of the biliary tree is an accepted protocol for the management of bronchobiliary fistulas and persistent leaks after liver surgery; and this also cured our patient.3,4 Another interesting finding was the presence of gas in the abscess cavity due to which effective aspiration of the abscess could not be accomplished. This gas probably reached the abscess through some microcommunication with pulmonary parenchyma before it eroded into the bronchial tree. Gas in ALA may be taken as a warning sign of an impending pulmonary rupture. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Stanley SL Jr. Amoebiasis. Lancet 2003; 361: 1025–1034. 2. Shamsuzzaman SM and Hashiguchi Y. Thoracic amebiasis. Clin Chest Med 2002; 23: 479–492. 3. Liao GQ, Wang H, Zhu GY, Zhu KB, Lv FX and Tai S. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World J Gastroenterol 2011; 17: 3842–3849. 4. Gandini R, Konda D, Tisone G, Pipitone V, Aneslmo A and Simonetti G. Bronchobiliary fistula treated by self expanding ePTFE- covered nitinol stent-graft. Cardiovasc Intervent Radiol 2005; 28: 828–831.
Downloaded from tdo.sagepub.com at Gazi University on May 7, 2015
