Nonoperative management of grade IV liver laceration following blunt abdominal trauma complicated with delayed bilioplueral fistula

Abstract

The incidence of bile leaks following blunt liver trauma ranges from 0.5% to 21%. Bile leaks could give rise to biliopleural fistula, which can end up causing cholethorax, where a bilious effusion is seen in the pleural cavity. Early recognition of this condition is essential for favorable outcome. We report an unusual case of delayed biliopleural fistula causing cholethorax in a 30-year-old male, presented following blunt abdominal trauma following a motor vehicle collision. Abdominal examination revealed tender right upper quadrant. He was haemodynamically stable following initial resuscitation. Computed tomography of the abdomen revealed American Association for the Surgery of Trauma grade IV liver laceration without active extravasation of contrast, causing a moderate haemoperitoneum. Decision was made to manage the liver injury conservatively. Repeat imaging performed on day 11 due to progressive abdominal distension revealed bilateral pleural effusions and increased amount of abdominal free fluid. Bilateral intercostal tubes and an ultrasound-guided pigtail catheter was inserted to the abdomen. The right-sided intercostal(IC) tube drainage found to be bilious, along with a bilious drainage through the pigtail catheter placed on the peritoneal cavity. Due to persistently high drain output, an endoscopic retrograde cholangiopancreatography performed revealed a contrast leakage at cystic duct. Sphincterotomy was performed and a biliary stent was placed. Patient completely recovered following decompression of biliary system. The unusual presentation of biliopleural fistula requires a good clinical acumen for early diagnosis. Timely endoscopic and interventional radiological management for biliary decompression and drainage are required for a successful outcome.