Percutaneous sclerosis of an external biliary fistula

Abstract

An 8-month-old male infant was referred from Saudi Arabia for the management of portal hypertension and a mass in the liver involving the right lobe. An arteriogram showed the mass to be hypovascular. Surgical resection of the right hepatic lobe showed the mass to be a large abscess, which had developed after an exchange transfusion via the umbilical vein for rhesus incompatibility. Thus, portal vein thrombosis had resulted in not only portal hypertension, but also ascending infection of the right lobe. Of interest was the histology of the left lobe, which was consistent with polycystic liver disease. The infant remained cholestatic after the surgery, with signs of portal hypertension. The ascites and jaundice disappeared in the ensuing 3 months, but a small cutaneous biliary fistula developed at that time and later sealed off temporarily. Six months later, persistent redness in the area of the old cutaneous fistula prompted sonographic examination, which revealed a 3 x 3 cm collection immediately underneath the skin. A drain was introduced, establishing a biliary-cutaneous fistula, which soon drained over 100 ml per day. He remained afebrile on oral treatment with trimethoprim-sulfamethoxazole, but in view of the persistent bile drainage, a fluoroscopically controlled injection of 1 .5 ml of contrast medium was carried out with a balloon catheter in the intrahepatic track. Only the lateral segment of the right lobe was filled, with no communication to the rest of the biliary tree or the intestine (fig 1). Once the contrast material had been drained out, 1 ml of 95% ethyl alcohol plus 2% tnfluoroacetic acid (TFA) was injected with a balloon again inflated and left in contact with the biliary system for 10 mm. The patient was observed in the hospital over the next few days. He did not become febrile, his liver function tests remained normal, and there was no elevation of the white blood cell count or sedimentation rate. The bile drainage decreased to less than 30 mI/day. The procedure was repeated 1 week later. The contrast study showed less opacification of the biliary tree (fig. 2). Again, abcohol/TFA was injected and left in place for about 10 mm. After a third sclerosing treatment with 0.4 ml alcohol/TFA, the fistula closed off completely. Nine months later, the fistula was still closed, and no collections were detected by repeat sonographic examination. Discussion