Sonographic diagnosis of a bronchobiliary fistula after multiple hepatobiliary surgeries due to the cholangiocarcinoma

Introduction: Bronchobiliary fistula (BBF) is a rare condition defined by formation of a passageway between the biliary system and the bronchial tree and is usually associated with hepatic abscess (pyogenic, hydatid or amebic), trauma, biliary obstruction and liver surgery. Bilioptysis is a pathognomonic sign of BBF which is commonly evaluated with radiologic and endoscopic methods. We present a case of BBF where abnormal communication was discovered by abdominal ultrasound.

Case presentation: A 76 year old male patient was presented to our hospital with one month history of productive cough highly suspicious of bilioptysis. Four years ago he underwent two consecutive operations. First operation was due to the Mirizzi syndrome during which minimally invasive cholangiocarcinoma was coincidentally discovered. During second operation intrabiliary stent was placed and no remote metastases were found. Last year patient developed subphrenic abscess, hence surgical evacuation and drainage were performed.

On admission chest X-ray showed inhomogeneous opacity in lower right pulmonary lobe and slightly blurred right diaphragmatic line. Abdominal ultrasound showed inhomogeneous liver echostructure in subdiaphragmal area, defective diaphragm, liquid collection in lower right thorax and supposed communication between bronchial and biliary systems. Bronchoscopy confirmed biliary content in right bronchi. Surgical exploration showed probable site of abnormal communication and external drainage was performed. Endoscopic retrograde cholangiopancreatography showed obliterated biliary stent with stenosis of d. choledochus below the confluens. Obliterated stent was extracted and two plastic stents were placed at the site of stenosis which resulted with spontaneous closure of bronchobiliary fistula and ceasing of bilioptysis.