Cholethorax following Percutaneous Transhepatic Biliary Drainage

We report the case of a 51 year old man who developed the unusual complication of a bilious pleural effusion, or 'Cholethorax' following percutaneous transhepatic biliary drainage. Case Report: A 51 year old man with locally advanced gastric adenocarcinoma presented with painless jaundice one year following the completion of palliative chemotherapy. Laboratory investigations revealed a bilirubin level of 299 µmol/L with AST 117 U/L, ALT 134 U/L, GGT 2447 U/L, ALP 2159 U/L and an ultrasound of abdomen confirmed the presence of biliary obstruction. Percutaneous Transhepatic Cholangiography (PTC) was arranged as the presence of a gastric tumour precluded an approach using Endoscopic Retrograde Cholangiopancreatography (ERCP). The right hepatic duct was cannulated and contrast injected, demonstrating a complicated stricture of the common bile duct. An internal-external biliary drain was then inserted across this stricture to decompress the biliary tree and the position of the drain is shown in figure 1. Three days after the PTC our patient complained of severe right sided pleuritic chest pain and shortness of breath. A chest x-ray revealed right basal atelectasis and provisional diagnoses of a lower respiratory tract infection and possible pulmonary embolus were offered. Over the next 48 hours the patient became increasingly dyspnoeic, with signs of a right sided pleural effusion on Letters examination, and so a repeat chest radiograph was carried out (fig 2). The output of bile into the drainage bag had dramatically decreased and the bilirubin level had risen further to 387 µmol/L. A pleural aspiration was performed which yielded dark brown pleural aspirate with a bilirubin level of 766 µmol/L (fig 3). A diagnosis of a bilious pleural effusion (Cholethorax) as a complication of percutaneous transhepatic biliary drainage was made. The insertion of a 28F chest drain and rapid drainage of the bilious pleural fluid provided immediate relief of the shortness of breath and pleuritic chest pain. A further PTC was carried out urgently and three self-expanding metal stents were inserted across the complicated biliary stricture to provide adequate biliary drainage. Discussion: PTC and biliary drainage is used for the management of malignant biliary obstruction in cases where ERCP is inappropriate or has been unsuccessfully attempted. It involves the percutaneous cannulation of either hepatic duct followed by placement of a biliary drain to decompress the biliary tree and subsequent insertion of a stent during the initial procedure or a number of days later. During biliary cannulation it may be …