BILIOPTYSIS: AN UNUSUAL CLINICAL FINDING

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bilioptysis means presence of bile in the sputum. It has been previously identified in the setting of acute chest syndrome, hepatic infections such as echinococcosis and amebiasis, and bronchobiliary fistulae.1 We discuss a rare case of bilioptysis in the setting of fulminant liver failure, of which only one other case has been reported.2 This unique clinical constellation is one that likely portends a poor prognosis among those critical. CASE PRESENTATION: 47-year-old man with significant alcohol abuse was admitted to the ICU for fulminant liver failure and lacticemia. He presented with two episodes of hemoptysis and worsening jaundice. He took no pertinent medications. Exam was notable for ascites, severe jaundice, hepatosplenomegaly and spider angiomas. Labs were remarkable for AST 244, ALT 78, bilirubin 26.8, albumin 2.1, platelets 134, INR 2.2, hemoglobin 12.6, creatinine 3.14 and lactic acid 5.0. ICU course was complicated by worsening mental status, vasodilatory shock, renal failure requiring continuous renal replacement therapy, and acute hypoxemic respiratory failure requiring mechanical ventilation. He had increasing yellowish-green secretion on endotracheal suction with worsening infiltrates on chest X-ray. Bronchoscopy demonstrated copious yellowish fluid in the lower airway. BAL also showed biliary-tinged fluid. Despite aggressive management, he died in the setting of multiorgan failure from severe liver failure. DISCUSSION: We believe that bilioptysis in our patient was secondary to increased alveolar permeability causing bilirubin leakage. The patient did not have sickle cell disease and had no imaging evidence of fistulae. The secretions were unlikely of gastric origin given the presence of intact endotracheal tube cuff and intermittent suction on the orogastric tube. Bilirubin with molecular weight of 584 acts similar to high molecular weight serum proteins. Pleural fluid to serum bilirubin ratio >0.6 has been used for differentiating exudative from transudative effusion, especially in resource limited settings where LDH is difficult to obtain to meet Light’s criteria.3 Systemic inflammation generated by decompensated liver disease increases the permeability of capillary alveolar membrane, causing the diffusion of bilirubin according to concentration gradient. This can be seen as worsening infiltrates on chest X-ray. The unusual discoloration of the BAL should prompt a dipstick test for bilirubin, which can help differentiate between cardiac and non-cardiac causes of pulmonary edema and assess the prognosis in critically ill patients. CONCLUSIONS: In fulminant liver failure, this rare finding of bile in sputum or tracheal secretions could potentially be useful in establishing the diagnosis of the underlying pathology and assessing the prognosis in the critically ill patient. Reference #1: 1. Saraya, T. et al. A new diagnostic approach for bilious pleural effusion. Respir. Investig. 54, 364–368 (2016). Reference #2: 2. Choong, C. V., Chai, G. T., Lew, S. J. W. & Lim, A. Y. H. Bilioptysis: A Rare Finding with Valuable Information. in C52. CRITICAL CARE CASE REPORTS: UNUSUAL GI CAUSES OF CRITICAL ILLNESS A5805–A5805 (American Thoracic Society, 2017). doi:10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A5805 Reference #3: 3. Agrawal, P., Shrestha, T. M., Prasad, P. N., Aacharya, R. P. & Gupta, P. Pleural Fluid Serum Bilirubin Ratio for Differentiating Exudative and Transudative Effusions. JNMA J. Nepal Med. Assoc. 56, 662–665 (2018). DISCLOSURES: No relevant relationships by Eric Ahlstrom, source=Web Response No relevant relationships by Kejal Gandhi, source=Web Response No relevant relationships by Khushali Jhaveri, source=Web Response No relevant relationships by Emil Oweis, source=Web Response