" 25 year old male with history of fire arm injury 3 months back which resulted in perforation of stomach pancreas. Pt underwent repair & liver tear packing was also done which was later on removed. Patient developed intermittent fever, vomiting and cough. Patient was suspected to have liver abscess and an exploratory laprotomy was done but no abscess was found. Now the vomiting and cough are more persistent with fever. Patient was sent to our department for heptobiliary study. We planned a HIDA Scan with initial dynamic study of 30 min in anterior projection followed by the static spot views in anterior posterior and lateral projections.
Shazia Fatima
Reference: Case of the month, published in EJNM & MI image of month in July 2010
A 22-year-old male patient suffered a grade IV liver injury with haemoperitoneum in a roadside accident 2 months earlier, for which laparotomy and biliary stenting were done. However, after a few days, the stent was passed during defecation. A week later, the patient developed intractable cough with copious expectoration of green sputum. Chest X-ray showed right-sided pleural effusion with consolidation in the right lower lobe. Sputum examination confirmed the presence of bile, which raised the suspicion of a biliobronchial communication. [99mTc]Mebrofenin hepatobiliary scintigraphy (HBS) showed preserved function in the right lobe of the liver and impaired uptake in the left lobe. Static planar images from 45 min to 2 h showed unobstructed biliary drainage into the intestine caudally, with a streak of tracer passing cranially into the chest cavity that subsequently mimicked the shape of the central airways. SPECT/CT scan identified activity in the bronchi and trachea as a result of bronchobiliary fistula subsequent to thoracoabdominal trauma . Clinical presentation is fever, dyspnoea, cough and biliptysis, which is considered pathognomonic of fistula formation. Planar HIDA is reported to be a reliable in this situation.
Shazia Fatima
Thank you for submitting a case report for discussion to the this blog.
ReplyDeleteQAISAR SIRAJ
Why the patient referred to NM department?
ReplyDeleteDid he have jaundice?
Initial mild focus near the inferior border of liver's right lobe seems to be a biliary leak...
ReplyDeleteactivity is also seen to be going through stoamch; as we can visulaize the gastric fundus plus it also seems to be climbing towards the esophagus (linear activity conforming with a tubular structure)...
a long shot.. fever could be due to infection at biliary leak site and vomiting/ cough due to gastric mucosal irritation..
A CT abdomin with contrast and abdomina ultrasound findings are mandatory to coment on this scan otherwise it would be a bit of speculations. If other imaging studies are availbale then I would like to see them. If that is not restricted by the member posting the case..
ReplyDeleteIn fact that anonymous person is me
ReplyDeleteDr. aakif Ullah Khan
If other imaging details are not provided then it appears as collection of activity initially below the liver then a steak comming down disappearing in upper abdomin and on delayed images appearing inthe left lower abdomin. The left sided biliary channels also appear dilated cholestasis (Post inflamatory)
ReplyDeleteThe scan findings are suggestive of Biliary leak leading to biliary peritonitis (causing fever and vomitting) and left paracolic collection of all the inflamatory and biliary fluid.
Dr Fida: Patient was referred for assessing the hepatobiliary dynamics.
ReplyDeleteDr Aakif patient had CT scan (twice) as well as the Ultrasound but i would share their findings later on.
Please go ahead and describe what you see. The descriptions we have so far are interesting.
If u were to report this scan what next would u like to do?
a persistent focus postero-superior to right lobe of liver probably represent biliary leak into thorax.
ReplyDeletevariable abdominal activity likely physiologic tracer flow in gut.
a chest x-ray or CT chest would be next step.
Dr M Asif Rafique
A biloma most likely. The activity passes initially straight into the gut. But then there is a channel coursing towards the flank and a transient focus of activity below the right lobe whch I presume is a bile leak if not activity in a drain in situ. However, we are left with the focal retention as described. All ties in with the patient's symptoms.
ReplyDeleteI think there is delayed tracer transit from the the right lobe of the liver with persistent/collection of activity in the right biliray channels possibly due to post surgical stricture with biliary leaks
ReplyDeleteI have few queries
1.what was the site of contusion in liver
2. is there is any repair anstomosis mentioned in his operation notes.
MR Cholangiography is the procedure of choice for final diagnosis
DR. KHALIDA KHURSHID
The activity in the right lobe of liver that became apparent at 20 minutes and stayed afterwards can be due to aberrant intra hepatic gallbladder.
ReplyDeleteDr. Ambreen Khawar
and then there is this small focal defect seen in the dome of the right lobe of the liver - could that be attributable to the liver laceration or a tiny non-biliary collection. US shall show all of these. CT and US together with HIDA scan should clinch the diagnosis.
ReplyDeleteThe details of the injury and surgery which i retrieved from the patient's note were very sketchy. Type of laceration or type of surgery was not mentioned. but there was no drain in situ present. MR cholangiogram may be the procedure of choice but it was not done in this patient. The tracer collection in the right lobe was definitely not intrahepatic gall bladder.
ReplyDeleteUltrasound of the patient done prior to HIDA scan showed 12x8 cm collection in Right heptic lobe which was queried as abscess.
keep thinking we have still have few more images to come........
It can be intrahepatic chole docal cyst. Did the activity decreased in further delayed images. As with choledocal cyst the features of vomiting, fever can occur
ReplyDeletenow since we have such much to ponder about.. can we have next set of images ?
ReplyDeleteThe new set of images that I recieved on my email account:
ReplyDeleteShowactivity ging up in the right sided chest and then later can be seen on the other side as well.
Activity in the abdomin is also seen increased...
Broncho-biliary fistula.............????
This would have been evident if you could show these images early...
But still a nice case to comment.
Thank you Dr Aakif, Dr Asif, Dr Khalida. Dr Ambreen, Dr Fida, Dr Zaheer and Anonymousx3, for your contribution and valuable comments about this case.
ReplyDeleteI must thank Dr Qaisar Siraj, without his help it was impossible to load this case here and especially the second set of images as i did not know what to do with them and i posted them somehow in wrong place.
It was a case of bronchobiliary fistula. Its etiology difficult to ascertain as it could have been the consequence of initial injury or some complication of the surgical manipulation which patient had after firearm injury.
I know it would have been evident if i have posted these images earlier but this was just an exercise to make our minds ready to see unexpected things at unlikely places.
When we started this case we were also suspecting to see leak somewhere in the abdomen or around the liver but things were unfolded when we proceeded into the study.
Retrospectively we dug out the relevant information. We were told in history that patient had cough but it was not mentioned sputum was stained with bile. This clinical information is the pathognomonic sign of Bronchobiliary fistula. But patient was giving history of Vomiting with bouts of cough simultaneously and according to the patient vomitus had greenish color. in reality it was the biliptysis.
Patient came to us with very little clinical information and relevant investigations. At the time of presentation he only had abdominal ultrasound report which i shared with you yesterday. We requested patient to send his investigation to us which he provided later on.
On CT Scan Patient had low attenuation fluid density of 10x8 cm in right lobe.There was query about a communication of area to the right sided chest cavity as the outline cupola of diaphragm on right side was indistinct.
There are few more images i would be uploading (provided i can do it right.
Dr Shazia: Congratulations on an excellent case report presentation and discussion. You kept us all in the dark and quite in suspense, till the very end.
ReplyDeleteThanks to all those who participated with their valuable comments.
I am sorry I had to edit the text of the case of the month published in EJNM&MI that Shazia referred to and delete the images due to breach of copyright.
A good case for a write up since there aren't many such reported in the literature.
Now we shall await the next case presentation and I would encourage colleagues to participate.
QAISAR SIRAJ
PS: to be fair to those participants who commented, there was no clue in any of the images initially presented to suggest the presence of a bronchobiliary fistuala. The description of the findings by the participants were generally correct. Further, the suspision of a leakage in the right flank hasn't been refuted nor was anyone wrong in detecting and commenting on the nature of the collection in the liver. Aafik did very well to diagnose brochobiliary fistula the moment the images were shown. So well done everyone.
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