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Year : 2015  |  Volume : 32  |  Issue : 4  |  Page : 389-391  

A rare pleural effusion in a young male

1 Department of Anatomy, North Bengal Medical College and Hospital, Sushrutanagar, Siliguri, Darjeeling, West Bengal, India
2 Department of Pulmonary Medicine, College of Medicine, and Sagar Dutta Medical Hospital, Kolkata, West Bengal, India

Date of Web Publication30-Jun-2015

Correspondence Address:
Subhasis Mukherjee
181/2B, Roypur Road, Kolkata - 700 047, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-2113.159589

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A 28-year-old male presented with fever with right-sided chest pain for 2 weeks. Clinicoradiological picture was suggestive of right-sided pleural effusion. He had history of polytrauma following a road traffic accident and had to undergo emergency laparotomy a month ago. Microscopic and culture examination of the pleural fluid showed neutrophilia, high bilirubin content and presence of gram-negative bacilli. Ultrasound of the abdomen showed the presence of biloma in the liver and right subdiaphragmatic space with fistulous communication into the right thoracic cavity. The patient was managed successfully with complete recovery.

Keywords: Biliopleural fistula, biloma, pleural effusion

How to cite this article:
Begum S, Mukherjee S, Biswas D, Misra AK, Ghosh P, Bhanja P. A rare pleural effusion in a young male. Lung India 2015;32:389-91

How to cite this URL:
Begum S, Mukherjee S, Biswas D, Misra AK, Ghosh P, Bhanja P. A rare pleural effusion in a young male. Lung India [serial online] 2015 [cited 2020 May 30];32:389-91. Available from: http://www.lungindia.com/text.asp?2015/32/4/389/159589

   Introduction Top

Bilious pleural effusion is an extremely rare cause of pleural effusion. [1],[2] It usually occurs after surgical exploration of the biliary tree, [3],[4] but traumatic disruption of hepatobiliary system leading to bilothorax is also reported in the literature. [2] Irrespective of the etiology, thoraco-biliary fistulous and bilothorax put the clinicians in diagnostic as well as therapeutic dilemma. We report a case of delayed formation of biloma following a road traffic accident (RTA) complicated with a subdiaphragmatico-pleural fistula, a month after the RTA.

   Case Report Top

A 28-year-old male, auto-rickshaw driver by profession, presented to us with high grade fever and right-sided pleuritic chest pain for a duration of 10 days. He had a history of RTA about 6 weeks ago. He sustained a blunt injury to his abdomen and a Colle's fracture of his right hand. He underwent surgical control of lacerated liver injury. He required four units of whole blood transfusion in the perioperative period, and had an uneventful immediate postoperative recovery. On clinical examination, the patient was febrile, pallor and icterus were absent. Examination of the respiratory system revealed dull percussion note and diminished breath sound over the right chest, however there was no percussion tenderness.

A plain Chest X-ray (PA) view revealed a right-sided encysted pleural effusion [Figure 1]. Blood investigations showed normal hemoglobin but with leukocytosis (total leukocyte count- 14600/cu.mm), predominantly neutrophils. Liver function test was normal. Aspiration of the pleural fluid was carried out, macroscopically the fluid was turbid, mustard yellow in color, almost bile-like in appearance; hence, pleural fluid bilirubin level and other relevant studies were performed. Pleural fluid was exudative, cell count was increased (4300/cumm) with neutrophilic preponderance, adenosine deaminase was negative (10.7 U/l). On Gram staining showedthere was the presence of gram-negative bacilli but culture was negative, Ziehl-Neelsen stain was negative as well. Pleural fluid bilirubin was found to be 6.8 mg/dl. He was diagnosed as bilious pleural effusion with superadded bacterial infection. Ultrasound (USG) of the abdomen was done. It revealed two small hypo-echoic, round encysted collections, one in the left lobe of liver (segment VII) and the other in the subdiaphragmatic space, a fistulous tract was seen communicating between right pleural space and the collection in subdiaphragmatic space [Figure 2]. The findings were suggestive of biloma(s). However, percutaneous drainage of the bilomas was not feasible as the collections were too small. Instead, the patient was managed conservatively i.e. pleural fluid was aspirated on two occasions 800 ml and 600 ml respectively and he was put on intravenous broad spectrum antibiotics (piperacillin-tazobactum and clindamycin). Follow-up CXR-PA view after 1 week showed minimal pleural effusion with residual pleural thickening. A repeat USG abdomen showed the two cysts had diminished significantly in size and the fistulous communication was no longer visualized. The patient underwent full recovery and was discharged well in a stable condition. On follow-up visit after 3 months, the patient was absolutely well; there were no pallor or icterus clinically. Examination of the respiratory system was also normal with the presence of normal breath sounds on both sides. Radiologically, the CXR was normal with minimal pleural thickening on the right side, USG of the abdomen also showed complete resolution of the biloma(s) and no fistulous tract could be identified [Figure 3].
Figure 1: Chest X-ray PA view showing right-sided encysted pleural effusion

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Figure 2: USG of abdomen showing two biloma, pleural effusion and the fistulous communication (Horizontal arrow) between the pleural space and the biloma in the subdiaphragmatic space (vertical arrow)

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Figure 3: Follow-up Chest X-ray and USG of the abdomen after 3 months demonstrating complete radiological clearance of the pleural effusion and biloma(s), respectively

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   Discussion Top

Lungs and the liver are two adjacent viscera, hence lung-liver interface is not uncommon entity to pulmonologists. Clinically, possibility of a liver or subdiaphragmatic pathology has to be considered in all cases of right-sided pleural effusion. Liver abscess or subdiaphragmatic abscess are the common entities causing pleural effusion, but biloma with a fistulous communication with pleural space as an etiology of pleural effusion is extremely uncommon in the published literature. [1],[3] Bilothorax can be iatrogenic or even rarely spontaneous. Laparoscopic or open surgical procedures of the hepatobiliary tree or blunt trauma are among the few causes of iatrogenic bilothorax. [3],[4],[5],[6],[7],[8] On rare occasions, spontaneous bilio-pleural fistula can occur in patients with gall stones. [9] Rarely bile can reach directly to the bronchial tree by means of a broncho-biliary fistula and results in bilioptysis. [10] Bilothorax does not develop immediately following trauma, as the fistulous tract usually takes an average time of 2 weeks to mature and hence it is usually missed during initial emergency surgery. [11] In this case, the small biloma with the narrow fistulous communication between the subdiaphragmatic space and the pleura may not have been visualized during laparotomy and resulted in the leakage of bile causing bilious pleural effusion one month after the initial trauma. The proposed mechanism of formation of pleurobiliary fistula following injury to the biliary tree is formation of biloma and subsequent rupture of the biloma into the pleural cavity through the transdiaphragmatic route following the path of least resistance. [3],[11] Passage of the bile through the connective tissue sheath of esophagus and great vessels to reach the posterior mediastinum and subsequent spillage from there into the pleural cavity or bronchus has been postulated as another theory for thoraco-biliary fistulas. [3]

Diagnosis of bilothorax requires high index of clinical suspicion. On gross examination of the pleural fluid, greenish-yellowish tinge of the pleural fluid may give hint toward the presence of bilirubin in the pleural fluid and the diagnosis is confirmed by estimation of bilirubin in the pleural fluid and a pleural fluid to serum bilirubin ratio greater than one. [12] Once the bilothorax is confirmed, the next step in diagnosis is to find out the fistulous communication between the pleural space and the biliary tree. Hepatic scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP) usually demonstrate the biliary leak and the fistulous communication. [13],[14] USG of the abdomen is usually not a very sensitive tool for visualization of the fistulous tract but should always be done as a baseline test as it is inexpensive and at times can clinch the diagnosis by demonstrating the biloma and the fistulous tract and hence obviates the need for further invasive or expensive radiographic procedures as in our case.

Bilious pleural effusion poses therapeutic challenge to clinicians as bile is a very good nidus for bacterial infection. [3],[6] In our patient, the pleural fluid was infected and it was manifested systemically as high grade fever. Increased pleural fluid cell count with neutrophilia and presence of gram-negative bacilli on Gram's stain also supported the evidence of the infection. The sequelae of bilo-thorax is fibrothorax as bile is a fibrogenic agent, hence delay in drainage of pleural fluid can rapidly give rise to a permanent state of compromised lung function. [4] Another rare but fatal complication of bilo-thorax is acute respiratory distress syndrome. [15] Early drainage of the pleural fluid either by intercostal tube or pig-tail catheter; or repeated therapeutic aspirations in case of multiple encysted fluids along with institution of broad spectrum antibiotics is the standard recommendation for management of bilo-thorax. [16],[17] Transabdominal percutaneous drainage of the biloma has also proven to be beneficial in some cases. [3] Regarding the management of the bilio-pleural fistula, the fistulous tract usually heals spontaneously without any need for surgical intervention. [2],[16],[17],[18]

In conclusion, though it is a rare entity, bilo-thorax is a diagnosis to should be kept in mind as a differential diagnosis in a case of right sided pleural effusion, especially after liver trauma or surgical intervention to the hepatobiliary tree. Early administration of broad-spectrum antibiotics with prompt therapeutic drainage of the pleural fluid will ensure a successful outcome.

   References Top

Basu S, Bhadani S, Shukla VK. A dangerous pleural effusion. Ann R Coll Surg Engl 2010;92:W53-4.  Back to cited text no. 1
Kajal NC, Lal B, Gupta S, Attri R, Gupta O, Kajal N. Conservative management of post traumatic thoraco diaphragmatico biliary fistula. Lung India 2010;27:242-3.  Back to cited text no. 2
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Hamers LA, Bosscha K, van Leuken MH, Moviat MA, de Jager CP. Bilothorax: A bitter complication of liver surgery. Case Rep Surg 2013;2013:372827.  Back to cited text no. 3
Aydogan A, Sukru Erden E, Akkucuk S, Davran R, Yetim I, Veli Ozkan O. Cholethorax (bilious Effusion in the Thorax): An unusual complication of laparoscopic cholecystectomy. Arch Iran Med 2013;16:489-90.  Back to cited text no. 4
Prabhu R, Bavare C, Purandare H, Supe A. Pleuro-biliary fistula--a delayed complication following open cholecystectomy. Indian J Gastroenterol 2005;24:28-9.  Back to cited text no. 5
Lee MT, Hsi SC, Hu P, Liu KY. Biliopleural fistula: A rare complication of percutaneous transhepatic gallbladder drainage. World J Gastroenterol 2007;13:3268-70.  Back to cited text no. 6
Prodromos P, Condilis N. Thoracobiliary fistula. A rare complication of thoracoabdominal trauma. Ann Ital Chir 2009;80:67-70.  Back to cited text no. 7
Andrade-Alegre R, Ruiz-Valdes M. Traumatic thoracobiliary (pleurobiliary and bronchobiliary) fistula. Asian Cardiovasc Thorac Ann 2013;21:43-7.  Back to cited text no. 8
Cunningham LW, Grobman M, Paz HL, Hanlon CA, Promisloff RA. Cholecystopleural fistula with cholelithiasis presenting as a right sided pleural effusion. Chest 1990;97:751-2.  Back to cited text no. 9
Fröbe M, Kullmann F, Schölmerich J, Böhme T, Müller-Ladner U. Bronchobiliary fistula associated with combined abscess of lung and liver. Med Klin (Munich) 2004;99:391-5.  Back to cited text no. 10
Feld R, Wechsler RJ, Bonn J. Biliary-pleural fistulas without biliary obstruction: Percutaneous catheter management. AJR Am J Roentgenol 1997;169:381-3.  Back to cited text no. 11
Pisani RJ, Zeller FA. Bilious pleural effusion following liver biopsy. Chest 1990;98:1535-7.  Back to cited text no. 12
Yong ML, Joyce JM, Weinberg LM, Christie NA. Biliary pleural fistula detected by hepatobiliary scintigraphy. Clin Nucl Med 2005;30:281-3.  Back to cited text no. 13
Jewis JR, Te HS, Gehlbach B, Oto A, Chennat J, Mohanty SR. A case of biliopleural fistula in a patient with hepatocellular carcinoma. Nat Rev Gastroenterol Hepatol 2009;6:248-51.  Back to cited text no. 14
De Luca D, Minucci A, Zecca E, Piastra M, Pietrini D, Carnielli VP, et al. Bile acids cause secretory phospholipase A2 activity enhancement, revertible by exogenous surfactant administration. Intensive Care Med 2009;35:321-6.  Back to cited text no. 15
Cooper AZ, Gupta A, Odom SR. Conservative management of a bilothorax resulting from blunt hepatic trauma. Ann Thorac Surg 2012;93:2043-4.  Back to cited text no. 16
Singh B, Moodley J, Sheik-Gafoor MH, Dhooma N, Reddi A. Conservative management of thoracobiliary fistula. Ann Thorac Surg 2002;73:1088-91.  Back to cited text no. 17
Sheik-Gafoor MH, Singh B, Moodley J. Traumatic thoracobiliary fistula: Report of a case successfully managed conservatively, with an overview of current diagnostic and therapeutic options. J Trauma 1998;45:819-21.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]


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