Hepatology: Bilothorax after percutaneous transhepatic biliary drainage

Figure 2

Figure 1 space.

Coronal CT Scan showing the PTHBD traversing the pleural

Bilothorax (or cholethorax), describes the rare accumulation of bile in the pleural cavity, and is most commonly a complication of intra-abdominal surgery or blunt hepatic trauma. It has also been recognized as a rare complication of a percutaneous transhepatic biliary drain (PTHBD) placement, with only nine reported cases in the English-language literature of Bilothorax developing after PTHBD placement. We describe the unusual presentation of a bilothorax in 71-yearold male with a history of Whipple surgery for pancreatic cancer. The patient presented to the hospital with painless jaundice and fever. Imaging showed biliary dilation and recurrence of cancer at the site of the hepaticojejunostomy. A biliary drain was placed under fluoroscopic guidance. Biliary cultures grew Pseudomonas aeroguinosa and Enterococcus. The patient was discharged with the biliary drain in place to complete a course of intravenous antibiotics. One month later, the patient returned to the hospital with progressive dyspnea and imaging showed a large right-sided


Chest tube and PTHBD draining similar bilious fluid.

pleural effusion. A CT scan of the chest also demonstrated the biliary drain traversing the pleural cavity (Fig. 1). On thoracentesis, 1 L of infected biliary fluid was drained from the pleural cavity (Fig. 2). He was treated with broad-spectrum antibiotics and both a chest tube and biliary drain were left open. The patient developed a bowel perforation during his hospitalization and ultimately expired. Treating bilothorax consists of drainage, treatment of infectious sequelae, and correction of the underlying etiology. Early recognition is essential, and bilothorax should always be considered after drain placement if dyspnea develops. Since bile is conducive to bacterial growth; it is important to maintain suspicion of infection in settings where pleural effusions are difficult to aspirate. Awareness of this potential complication warrants extra caution in avoiding disruption of the pleural space during the procedure. Bilothorax should always be considered if the patient develops dyspnea at any time after drain placement. Contributed by M Bilal,* J Chong† and M Lega† *Allegheny General Hospital, Internal Medicine, and † Department of Pulmonary and Critical Care Medicine, Pittsburgh, Pennsylvania, USA

Journal of Gastroenterology and Hepatology 30 (2015) 802 © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd

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Education and imaging. Hepatology: Bilothorax after percutaneous transhepatic biliary drainage.

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