Introduction: Bronchobiliary fistulas (BBF) are rare, arising from an abnormal communication between the biliary tract and bronchial tree. Only about 13% of cases are due to hepatic metastases. Bilioptysis is pathognomonic. We present a case of BBF caused by complications of metastatic colon cancer.
Description: The patient is a 49yo female with metastatic colon cancer to the lung and liver, complicated by malignant biliary strictures causing bilomas that required internal-external biliary drain placement 6 months prior to admission and subsequent dilation. A double pigtail was placed into a biloma 1 month prior due to concern for infection. She presented to the Emergency Department with 1 day of fever and dyspnea. Vital signs were notable for hypoxia to 86%, tachycardia to 164, and a fever of 103.1. Chest x-ray demonstrated multifocal pneumonia. She was placed on high flow oxygen, started on antimicrobials, and admitted to the ICU. Her sputum culture grew Klebsiella and Enterobacter cloacae. Sputum was bright yellow and became more bilious, with a sputum bilirubin of 9.8 mg/dL. Her respiratory status worsened, and she was ultimately intubated. Bronchoscopy was unable to localize the source of bilioptysis.
CT imaging demonstrated a right middle lobe cavitary lesion and right loculated fluid collection contiguous with a hepatic dome biloma, concerning for a diaphragmatic defect and BBF. Her pigtail drain was upsized without improvement, so a percutaneous drain was placed 2 days later. She was not a surgical candidate for diaphragmatic repair, as there was concern her bilomas would continue to erode through a repair.
With increased drainage, the patient improved enough to be extubated. The drains have since been internalized as an outpatient and the subdiaphragmatic fluid collection is nearly resolved.
Discussion: There are currently no guidelines for BBF management as they are uncommon. While treatment traditionally was surgical fistulectomy and reconstruction, this has significant morbidity. We add to the developing literature supporting non-surgical therapy such as biliary stenting, percutaneous drainage, and ERCP. We report a critically ill patient requiring intubation due to a BBF from metastatic cancer, who successfully recovered with minimally invasive drainage.
