Iatrogenic Bilothorax: A Rare Complication of Orthotopic Liver Transplant

Spontaneous bilothorax without previous surgery or trauma, a case report

Bilothorax is a rare condition that can lead to severe infection and death. Most cases present with right-sided pleural effusion and the etiology can be biliary obstruction, infection, or iatrogenic complications. The diagnosis of bilothorax is confirmed by the ratio of pleural fluid to serum bilirubin >1. A 33-year-old Asian female presented with progressive dyspnea from right pleural effusion, which was confirmed to be biloma by pleural fluid to serum bilirubin ratio of 15.9. Imaging showed right-sided subdiaphragmatic nodule, which was subsequently biopsied on laparoscopy revealing hemorrhagic endometriotic lesion. However, there was no obvious diaphragmatic defect connecting pleural and peritoneal cavities. Additionally, no biliary leakage was identified by magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). The treatment included antibiotics, tube thoracostomy, ERCP with stent, thermal ablation of endometriotic nodules under laparoscopy, and hormonal therapy for endometriosis. Bilothorax is rare case itself but the etiology secondary to endometriosis makes this case particularly unique.

Bilothorax: A Case Report and Systematic Literature Review of the Rare Entity

Background

Bilothorax is defined as the presence of bile in the pleural space. It is a rare condition, and diagnosis is confirmed with a pleural fluid-to-serum bilirubin ratio of >1.

Methods

The PubMed, Embase, Google Scholar, and CINAHL databases were searched using predetermined Boolean parameters. The systematic literature review was done per PRISMA guidelines. Retrospective studies, case series, case reports, and conference abstracts were included. The patients with reported pleural fluid analyses were pooled for fluid parameter data analysis.

Results

Of 838 articles identified through the inclusion criteria and removing 105 duplicates, 732 articles were screened with abstracts, and 285 were screened for full article review. After this, 123 studies qualified for further detailed review, and of these, 115 were pooled for data analysis. The mean pleural fluid and serum bilirubin levels were 72 mg/dL and 61 mg/dL, respectively, with a mean pleural fluid-to-serum bilirubin ratio of 3.47. In most cases, the bilothorax was reported as a subacute or remote complication of hepatobiliary surgery or procedure, and traumatic injury to the chest or abdomen was the second most common cause. Tube thoracostomy was the main treatment modality (73.83%), followed by serial thoracentesis. Fifty-two patients (51.30%) had associated bronchopleural fistulas. The mortality was considerable, with 18/115 (15.65%) reported death. Most of the patients with mortality had advanced hepatobiliary cancer and were noted to die of complications not related to bilothorax.

Conclusion

Bilothorax should be suspected in patients presenting with pleural effusion following surgical manipulation of hepatobiliary structures or a traumatic injury to the chest. This review is registered with CRD42023438426.

Bilothorax: A Rare Complication of Percutaneous Transhepatic Biliary Drainage in a Patient With Primary Sclerosing Cholangitis

Bilothorax is a rare etiology of pleural effusions that involves leakage of bile from the biliary system into the pleural cavity. Most cases result from iatrogenic mechanisms, like endoscopic retrograde cholangiopancreatography. However, only a limited number of cases have reported this as a complication of percutaneous transhepatic biliary drainage. We report this rare presentation in an elderly man with primary sclerosing cholangitis after receiving percutaneous transhepatic biliary drainage for decompression of multiple complex biliary obstructions. Given its rarity and lack of established guidelines, we review clinical features, medical management, and potential implications of bilothorax, especially in patients with chronic liver disease and cirrhosis.

Nonoperative management of biliopleural fistula following living-donor liver transplantation: A case report

Key Clinical Message

Biliopleural fistula is a rare but serious complication after liver transplantation that should be managed nonoperatively with antibiotics, pleural drainage, decompression of high-pressure biliary tract, or ultimately surgery in unresponsive cases.

Abstract

Bilious pleural effusion is a rare entity often iatrogenic, following hepatobiliary surgeries and biliary interventions, and has been reported only in a limited number of patients after liver transplantation. A 5-year-old girl underwent living donor liver transplantation due to progressive familial intrahepatic cholestasis. At the 7th day of the postoperative course, due to increased liver enzymes and bilirubin levels and intrahepatic bile duct dilatation on sonography, Magnetic Resonance Cholangiopancreaticography followed by a liver biopsy were performed; the findings demonstrated moderate intrahepatic bile duct dilatation and moderate cellular rejection associated with mild cholestasis, respectively. The patient was therefore administered a pulse of methylprednisolone; however, due to fever, peritonitis and also sonographic evidence of infected biloma collection adjacent to the transplanted liver, the patient underwent surgery. Laparotomy and peritoneal washout were performed and a Jackson-Pratt drain was inserted adjacent to the liver cut surface. Succeeding tachypnea on 28th post day, led to detection of right side massive pleural effusion on chest Xray and hence thoracostomy tube was inserted. A diagnosis of biliopleural fistula was established and broad-spectrum intravenous antibiotic therapy was started, followed by cholangiography, fistula closure, and bile duct stricture ballooning and internal-external biliary catheter insertion. The patient was discharged in generally good condition on the 50th posttransplant day. The diagnosis of biliopleural fistula is facilitated with the utilization of chest imaging and pleural fluid analysis, however, a high index of suspicion is required.

Management of massive bilothorax post-percutaneous trans-hepatic biliary drainage

Background

Iatrogenic bilothorax is an infrequent major complication of percutaneous trans-hepatic biliary drainage (PTBD) and optimal treatment remains under-reported. The authors herein describe a case of PTBD complicated by a massive bilous effusion.

Case presentation

An 80-year-old male underwent PTBD due to malignant obstructive jaundice (total bilirubin 20.0 mg/dL). Following discharge, the patient was readmitted with severe dyspnea and recurrence of jaundice (total bilirubin 15.0 mg/dL). CT depicted the drainage catheter traversing the right costophrenic sulcus, complete obliteration of the right pleural space, no aerated right lung parenchyma and left mediastinal shift. The pleural effusion was successfully drained, and the biliary drainage catheter tract was sealed with Gelfoam pledgets and coils, to prevent bilopleural fistula formation and recurrence of the effusion.

Conclusions

In this case, a successful totally percutaneous management of iatrogenic bilothorax following PTBD is described. Due to the potential of rapid clinical deterioration and empyema formation, immediate evaluation and treatment are warranted. Prompt pleural drainage with antibiotic therapy and bile flow diversion from the pleural cavity are required.