University of Texas Rio Grande Valley - Doctors Hospital at Renaissance
Bronchobiliary fistula (BBF) is a rare condition where an abnormal connection is formed between the biliary system and the bronchial tree. Causes include amoebic diseases of the liver, trauma, biliary obstruction, and hepatobiliary surgery. Patients often present with biliptysis, which is pathognomonic for this condition. Importantly, BBF is associated with high morbidity and mortality rates. The management of this entity is challenging due to the rarity of the disease. We present a case of BBF successfully treated with deployment of a fully covered self-expandable metallic biliary stent during ERCP.
The patient is a 55-year-old woman with a history of well differentiated neuroendocrine tumor of the liver treated with transcatheter arterial chemoembolization, complicated by development of a liver abscess and then a biliary cutaneous fistula, s/p segment 4 liver resection, who presented to an outside facility for a 3 week history of RUQ abdominal pain, shortness of breath and biliptysis. She underwent a HIDA scan for evaluation of her RUQ pain and was found to have a BBF. An unsuccessful ERCP attempt was made and the patient was transferred to our center for surgical evaluation. Our team was consulted, and she underwent successful ERCP with a clear demonstration of a fistulous communication between the distal left hepatic system and the bronchial tree on cholangiogram. A 10Fr x80mm covered metal stent was deployed with complete resolution of the patient’s symptoms. She was seen weeks later in clinic and remained symptom free.
Discussion: The pathogenesis of BBF formation has not been completely understood, increased pressure within the biliary tree with local inflammation appears to be two major factors that contribute to its development. Diagnosis can be made with CT imaging or HIDA scan, as well as with interventional techniques, such as ERCP, percutaneous transhepatic cholangiography, bronchoscopy or fistulography. In our case, multiple causes are suspected to have provoked the formation of the fistula in this patient, including liver tumor, chemoembolization, abscess and hepatectomy. Due to its low incidence, there is no clear consensus on the treatment of this uncommon complication. According to published literature, best clinical outcomes were seen with surgical management. Our patient was successfully treated endoscopically with deployment of a biliary stent, thus providing a least invasive alternative to surgery when performed by a skilled gastroenterologist.
Cholangiogram showing bronchobiliary fistula at the distal left hepatic duct.
After deployment of fully covered self-expandable metallic biliary stent
Endoscopic view of metal stent.
Mohammed Shakhatreh indicated no relevant financial relationships.
Arturo Suplee Rivera indicated no relevant financial relationships.
Grigoriy Rapoport indicated no relevant financial relationships.
Carlos Cardenas indicated no relevant financial relationships.
Asif Zamir indicated no relevant financial relationships.