Hepato-Bronchial Fistula; a rare complication of Liver Abscess
SM". Husnain*a (Dr), R“. Shepherda (Prof), S. Shojaeea (Dr), SMN. Husnaina (Dr)
a Virginia commonwealth university, Richmond, UNITED STATES
Acquired Hepato-Bronchial Fistula (HBF) is rare communication between Hepatic parenchyma and bronchial tree via diaphragm. It’s a rare entity and less than 70 cases are described in literature1. Unlike congenital causes, Acquired types are caused by hydatid or amebic disease of the liver, hepatic abscess, trauma, and neoplasm. Given its rarity they can be difficult to diagnose, manage and often associated with high morbidity and mortality.
We present a 45 yo male with pancreatic neuroendocrine tumor, chronic pancreatitis and biliary obstruction s/p drainage, gastrojejunostomy. After initial diagnosis, he presented with Pyogenic liver abscesses complicated by diaphragmatic rupture and empyema requiring VATS with decortication. Later in course, patient was found to have recurrent liver abscess, beneath diaphragm resulting in septic shock. Patient had 3 drains placed for abscess. He was found to have pneumobilia on one of the follow-up imaging. A contrast study was suspicious for fistula formation between airway and drain. bronchoscopy was performed to establish the diagnosis. A 5 mL of methylene blue was injected through a hepatic drain. A visualization of dye was instantaneously seen in third generation airway of right middle lobe with direct visualization. Subsequently hepatic drain was removed and recommendation was made for fistula to be healed. Patient continued on empiric antibiotic, and did relatively well without intervention.
HBF is a rare entity. Historically surgical drainage and repair have been used with little success and significant morbidity3. However this case already had drains placed and his source was controlled at the time of discovery of fistula. More importantly adequate antibiotics with definitive management biliary tract is essential4. CT scan, USG and MRI or direct visualization with dye injection can all be helpful and support diagnosis5. Careful assessment of this condition is needed if clinical suspicion is high, before therapeutic procedure6.
Disclosure of funding source(s): none