SHM Converge Scientific Abstract ePoster Gallery-Bilothorax: An Uncommon Sequelae of Partial Cholecystectomy

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This case describes a 73-year-old woman who developed bilothorax after a complicated partial cholecystectomy for acute cholecystitis. Her surgery was complicated by conversion to open surgery, an unclipped cystic duct, and hepatic capsule tearing, requiring placement of a gallbladder fossa drain and hepatic duct stent.<br /><br />After drain removal, she developed worsening right upper quadrant pain. Imaging showed a subcapsular hepatic fluid collection, and a new drain was placed. Cultures from the drained fluid grew VRE and Candida albicans, so she was treated with daptomycin, ceftriaxone, metronidazole, and fluconazole.<br /><br />By postoperative day 14, she developed pleuritic RUQ pain. CT imaging revealed a right pleural effusion and migration of the biliary stent. Thoracentesis removed 620 mL of exudative orange fluid. The pleural-to-serum bilirubin ratio was 1.33, supporting the diagnosis of bilothorax. Pleural cultures were negative, and cytology showed benign inflammatory cells. Repeat ERCP was performed for stent removal and replacement in the left and right hepatic ducts. Because repeat thoracenteses did not fully resolve the effusion, a thoracostomy tube was placed, with gradual improvement before removal on postoperative day 34.<br /><br />The report highlights that bilothorax is a rare but important cause of pleural effusion, usually due to biliary tract injury, fistula formation, abscess near the diaphragm, biliary obstruction, or iatrogenic hepatobiliary procedures. Diagnosis is best confirmed by pleural fluid analysis, especially when the pleural-to-serum bilirubin ratio is greater than 1.0. Treatment requires drainage, antimicrobials when indicated, and correction of the underlying biliary problem. Early recognition likely prevented further infectious complications in this patient.

Asset Subtitle

Jacob M. Beery

Meta Tag

Author List Jacob M. Beery, Priya Jain, Randa Hazam

Category Clinical Vignettes

Concept Bilothorax

Concept Pleural Fluid-to-Serum Bilirubin Ratio

Concept Pleural Effusion

Concept Pleural Fluid Bilirubin

Concept Hepatobiliary Procedure

Distinguished Non-Finalist

Presenter Organization Saint Louis University School of Medicine

Presenting Author Jacob M. Beery

Track Adult

Keywords

bilothorax

pleural effusion

cholecystectomy

biliary stent migration

pleural-to-serum bilirubin ratio

thoracentesis

ERCP

hepatic fluid collection

VRE infection

Candida albicans

Bilothorax

Pleural Fluid-to-Serum Bilirubin Ratio

Pleural Effusion

Pleural Fluid Bilirubin

Hepatobiliary Procedure