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CASE STUDY
A case of biliopleural fistula in a patient with hepatocellular carcinoma
Jeffrey R. Lewis, Helen S. Te, Brian Gehlbach, Aytekin Oto, Jennifer Chennat and Smruti R. Mohanty
Background. A 66-year-old white man with a history of cryptogenic cirrhosis complicated by hepatocellular carcinoma, ascites and hepatic encephalopathy presented with a productive cough and pleuritic chest pain on his right side. He underwent transarterial chemoembolization for hepatocellular carcinoma 6 months before presentation. The patient had a history of coronary artery disease, type 2 diabetes mellitus and hypertension.
Investigations. Medical history and physical examination, laboratory investigations, diagnostic thoracentesis, bacterial culture and Gram staining studies, abdominal MRI with magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, infused chest CT and examination of the thorax during open thoracotomy.
Diagnosis. Biliopleural fistula with connections between the right pleural space and a branch of the right intrahepatic biliary tree.
Management. Antibiotics, placement and removal of a chest tube, endoscopic retrograde cholangiopancreatography to guide biliary sphincterotomy with placement and removal of a hepatic-duct stent, open thoracotomy with decortication, percutaneous transhepatic cholangiography and placement of a catheter.
Lewis, J. R. et al. Nat. Rev. Gastroenterol. Hepatol. 6, 248251 (2009); http://www.nature.com/doifinder/10.1038/nrgastro.2009.34
Web End =doi:10.1038/nrgastro.2009.34
The case
A 66-year-old white man with a history of cryptogenic cirrhosis complicated by hepatocellular carcinoma, ascites and hepatic encephalopathy presented with a productive cough and pleuritic chest pain on his right side. He underwent transarterial chemoembolization for hepatocellular carcinoma 6 months before presentation. He also had a history of coronary artery disease, type 2 diabetes mellitus and hypertension.
A CT scan, which was obtained to evaluate chest pain, revealed findings that led to an initial diagnosis of HCC. This scan was followed by MRI with magnetic resonance cholangiopancreatography (MRCP), which revealed two liver masses. The first mass (4.4 3.6 cm) was in segment VII of the liver, and demonstrated a typical pattern of enhancement for HCC (Figure 1); a second mass at the junction of the right anterior and posterior biliary ducts measured 3.5 2.7 cm, but did not display typical radiographic features of HCC. The patients serum -fetoprotein (AFP) level was 24 ng/ml (normal value <9.0 ng/ml). The patient was listed for liver trans plantation and underwent TACE on two occasions (5 months and 8 months after diagnosis...