Endoscopic Retrograde Cholangiopancreatography Used to Treat a Biliobronchial Fistula in a Patient With Hepatocellular Carcinoma

Abstract

A biliobronchial fistula is an abnormal communication between the biliary tract and the bronchial tree. This type of fistula is a rare complication after treatment for hepatocellular carcinoma with transcatheter arterial chemoembolization (TACE). A 71 year old man presented to our hospital with cough productive of yellow sputum for 3 months prior to presentation that was not associated with fever. He also reported weight loss over the past 3 months as well as generalized fatigue. His medical history is significant for hepatocellular carcinoma, treated with TACE with doxorubicin 12 months ago. He was hospitalized at another hospital 3 months earlier when his cough started and was treated with antibiotics for suspected pneumonia and was discharged. His cough did not improve. Physical examination revealed dullness to percussion over the right lower lung field associated with rhonchi heard in the same field. Otherwise, examination was unremarkable. His initial presenting labs were normal apart from an Alpha fetoprotein level of 25,743. A right lower lobe consolidation was seen on chest x-ray. A sputum test for bilirubin revealed a level of 6.7 mg/dL. A HIDA scan was requested which showed a biliary leak into the right lower lung and trachea. The biliary leak was found to be secondary to a biliobronchial fistula. During hospitalization, an endoscopic retrograde cholangiopancreatography (ERCP) was performed with sphincterotomy and common bile duct stent placement to manage the biliobronchial fistula. The patient's cough and biliary sputum improved significantly after the stent was placed and he currently no longer has a cough or bilious sputum. A biliobronchial fistula may be a complication of hepatocellular carcinoma and its treatments. It has been reported to be associated with hepatocellular carcinoma treated with radiofrequency ablation and in cases treated with hepatectomy. Surgical management options have been used in previously reported cases and in this case, an ERCP with sphincterotomy and common bile duct stent was used to decrease biliary flow through the fistula. This successfully managed the patient's symptoms and will give the biliobronchial fistula an opportunity to close.Figure: HIDA scan showing biliary leak.Figure: Biliary leak demonstrated by ERCP.