Scientific letter
Hepatobronchial Fistula: A Rare Complication of Liver Abscess
Fístula hepatobronquial: una rara complicación de un absceso hepático
Martín Varela Vega
, Federico Durán, Nicolás Geribaldi, Gonzalo San Martín, Alejandro Ettlin
Corresponding author
Servicio de Cirugía General, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
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"paginaInicial" => "410" "paginaFinal" => "411" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Martín Varela Vega, Federico Durán, Nicolás Geribaldi, Gonzalo San Martín, Alejandro Ettlin" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Martín" "apellidos" => "Varela Vega" "email" => array:1 [ 0 => "martinvarelav@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Federico" "apellidos" => "Durán" ] 2 => array:2 [ "nombre" => "Nicolás" "apellidos" => "Geribaldi" ] 3 => array:2 [ "nombre" => "Gonzalo" "apellidos" => "San Martín" ] 4 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Ettlin" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía General, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fístula hepatobronquial: una rara complicación de un absceso hepático" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1777 "Ancho" => 1333 "Tamanyo" => 203954 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph: the instillation of water-soluble contrast material in the hepatic drain tube is seen in the airway.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hepatobronchial fistulae (HBF) are rare entities. They are defined as abnormal communications of a sector of liver parenchyma with a sector of the bronchial tree through a diaphragmatic pathway. First described by Peacock in 1850 in a patient with a hepatic hydatid cyst and hydatid vomica, its frequency has decreased, mainly due to the use of antibiotics in the presence of hepatic abscesses and the surgical treatment of hepatic and pulmonary hydatid cysts.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">HBF may be congenital or acquired. Acquired HBF (80%) is mainly caused by hepatic hydatid cysts that migrate toward the pleural cavity through the diaphragm. The other 20% are due to hepatic abscesses (amebic or pyogenic), lithiasis of the biliary tract and, less frequently, as a result of surgery or liver trauma.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Bronchobiliary fistulae (BBF) are those in which part of the biliary tract communicates with the bronchial tree, thereby perpetuating the pathway.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In these cases, the diagnosis is made more easily because the patient has a productive cough with biliary sputum (which characteristically stains the teeth yellow) in association with fever and leukocytosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">HBF that do not communicate with the bile duct, which are generally secondary to hepatic abscesses, are rarer. They do not present the characteristic bilioptysis, but instead purulent bronchorrhea, fed by the hepatic abscess. HBF usually appear in the context of a florid infection, with fever and leukocytosis, abdominal pain in the right hypochondrium and occasionally pleuritic pain and cough. They may present dyspnea of varying magnitudes and jaundice in some cases.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis is complemented with radiography and computed tomography (CT) studies. Therapeutic approaches range from conservative to minimally invasive to radical surgery (thoracic or thoracoabdominal), with diverse results.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Below, we present a case of HBF that was diagnosed and resolved by our department.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient is a 70-year-old man who underwent urgent surgery for acute cholecystitis. Surgery was initiated with a laparoscopic approach, which had to be converted to open surgery due to technical difficulties given the intense inflammatory process. There were no intraoperative incidents, patient progress was good, and antibiotic treatment was followed for 7 days.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was re-hospitalized 40 days later with cough, abundant purulent bronchorrhea that was brown in color, and fever. Laboratory tests showed: 17<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span>, prothrombin time 53% and hemoglobin 9.2<span class="elsevierStyleHsp" style=""></span>mg/dL. Chest radiograph showed evidence of inhomogeneous occupation of the right lung base. The patient presented respiratory insufficiency secondary to severe pneumonia; he was admitted to the ICU and thoracic and abdominal CT scans were ordered. The CT scans showed a heterogeneous collection in the hepatic dome (segments 7 and 8) that was 11–12<span class="elsevierStyleHsp" style=""></span>cm in diameter and compatible with abscess, a focal right basal consolidation and a moderate amount of pleural fluid (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment with ciprofloxacin and intravenous metronidazole was initiated empirically. We performed ultrasound-guided percutaneous puncture of the hepatic abscess, placing a 12<span class="elsevierStyleHsp" style=""></span>Fr Dawson Müller-type drain tube and obtaining 300–400<span class="elsevierStyleHsp" style=""></span>mL of brownish pus with the same characteristics as the patient's bronchorrhea. We observed that lavage of the abscess caused cough, which, together with the patient's surgical history and imaging studies, led us to the diagnosis of hepatobronchial fistula. The evidence of contrast material in the airway after instillation through the hepatic drain tube supported our diagnosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A pleural drainage tube was placed, which produced little turbid discharge that disappeared within 24<span class="elsevierStyleHsp" style=""></span>h.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The culture of the pus was positive for <span class="elsevierStyleItalic">Escherichia coli</span>, which was sensitive to the previously prescribed antibiotics. The pleural drainage catheter was removed after 3 days. The hepatic drains produced no bilious content; they were washed out daily, and their discharge was zero on the sixth day, so they were withdrawn. Follow-up CT scans after 1 and 6 months demonstrated resolution of the abscess and fistula.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We present a case of HBF as an unusual complication after urgent cholecystectomy, which is a frequent procedure. Although the diagnosis is more evident when the patient has bilioptysis, in cases in which there is no biliary communication the diagnosis is more difficult. A CT scan is the first imaging study to be done since it can define the outline of the liver abscess and assess any pulmonary involvement.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Ultrasound has a high sensitivity for defining hepatic lesions, and in this case it guided the evacuation puncture of the abscess. Magnetic resonance cholangiopancreatography (MRCP), ERCP or percutaneous transhepatic cholangiography may be useful to detect the fistula tract in cases of bronchobiliary communication.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> There was no need for ERCP in our patient, since there was no bile duct lithiasis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Traditionally, drainage of hepatic abscesses has been proposed, which was performed by means of open surgery in the era prior to percutaneous techniques, and perhaps pulmonary resection if the lung damage is considered irreversible, leaving in pleural and subdiaphragmatic drain tubes.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,6,7</span></a> Adequate antibiotic treatment is essential, and it is likewise necessary to verify the permeability of the bile duct.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,7</span></a> The advent of minimally invasive percutaneous techniques has allowed us to resolve the majority of cases that present with hepatic abscesses with less parietal aggression, as in the case of our patient.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Varela Vega M, Durán F, Geribaldi N, San Martín G, Ettlin A. Fístula hepatobronquial: una rara complicación de un absceso hepático. Cir Esp. 2017;95:410–411.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 717 "Ancho" => 800 "Tamanyo" => 85225 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT: liver abscess.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1777 "Ancho" => 1333 "Tamanyo" => 203954 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph: the instillation of water-soluble contrast material in the hepatic drain tube is seen in the airway.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case in which hydatids were expectorated and one of suppuration of hydatid cyst of the liver communicating with the lungs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T.B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 41 | 10 | 51 |
| 2024 September | 74 | 15 | 89 |
| 2024 August | 57 | 14 | 71 |
| 2024 July | 65 | 2 | 67 |
| 2024 June | 55 | 6 | 61 |
| 2024 May | 87 | 12 | 99 |
| 2024 April | 62 | 7 | 69 |
| 2024 March | 90 | 9 | 99 |
| 2024 February | 90 | 4 | 94 |
| 2024 January | 98 | 5 | 103 |
| 2023 December | 76 | 5 | 81 |
| 2023 November | 88 | 8 | 96 |
| 2023 October | 106 | 13 | 119 |
| 2023 September | 79 | 9 | 88 |
| 2023 August | 78 | 0 | 78 |
| 2023 July | 98 | 14 | 112 |
| 2023 June | 92 | 1 | 93 |
| 2023 May | 102 | 8 | 110 |
| 2023 April | 90 | 5 | 95 |
| 2023 March | 83 | 7 | 90 |
| 2023 February | 68 | 10 | 78 |
| 2023 January | 69 | 4 | 73 |
| 2022 December | 69 | 8 | 77 |
| 2022 November | 88 | 14 | 102 |
| 2022 October | 95 | 9 | 104 |
| 2022 September | 80 | 10 | 90 |
| 2022 August | 89 | 10 | 99 |
| 2022 July | 56 | 16 | 72 |
| 2022 June | 62 | 8 | 70 |
| 2022 May | 58 | 9 | 67 |
| 2022 April | 99 | 13 | 112 |
| 2022 March | 122 | 9 | 131 |
| 2022 February | 100 | 7 | 107 |
| 2022 January | 83 | 11 | 94 |
| 2021 December | 72 | 17 | 89 |
| 2021 November | 72 | 15 | 87 |
| 2021 October | 130 | 23 | 153 |
| 2021 September | 81 | 11 | 92 |
| 2021 August | 78 | 15 | 93 |
| 2021 July | 96 | 14 | 110 |
| 2021 June | 60 | 5 | 65 |
| 2021 May | 71 | 8 | 79 |
| 2021 April | 173 | 24 | 197 |
| 2021 March | 117 | 13 | 130 |
| 2021 February | 86 | 8 | 94 |
| 2021 January | 96 | 13 | 109 |
| 2020 December | 82 | 11 | 93 |
| 2020 November | 87 | 6 | 93 |
| 2020 October | 70 | 4 | 74 |
| 2020 September | 102 | 14 | 116 |
| 2020 August | 90 | 6 | 96 |
| 2020 July | 65 | 11 | 76 |
| 2020 June | 60 | 17 | 77 |
| 2020 May | 70 | 33 | 103 |
| 2020 April | 54 | 9 | 63 |
| 2020 March | 66 | 11 | 77 |
| 2020 February | 88 | 8 | 96 |
| 2020 January | 79 | 8 | 87 |
| 2019 December | 77 | 25 | 102 |
| 2019 November | 66 | 10 | 76 |
| 2019 October | 54 | 3 | 57 |
| 2019 September | 62 | 4 | 66 |
| 2019 August | 54 | 14 | 68 |
| 2019 July | 60 | 18 | 78 |
| 2019 June | 90 | 7 | 97 |
| 2019 May | 228 | 3 | 231 |
| 2019 April | 97 | 15 | 112 |
| 2019 March | 23 | 2 | 25 |
| 2019 February | 27 | 4 | 31 |
| 2019 January | 23 | 7 | 30 |
| 2018 December | 14 | 4 | 18 |
| 2018 November | 26 | 5 | 31 |
| 2018 October | 33 | 7 | 40 |
| 2018 September | 30 | 3 | 33 |
| 2018 August | 17 | 0 | 17 |
| 2018 July | 7 | 2 | 9 |
| 2018 June | 13 | 1 | 14 |
| 2018 May | 10 | 2 | 12 |
| 2018 April | 11 | 3 | 14 |
| 2018 March | 9 | 0 | 9 |
| 2018 February | 20 | 2 | 22 |
| 2018 January | 17 | 0 | 17 |
| 2017 December | 12 | 0 | 12 |
| 2017 October | 0 | 2 | 2 |
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