Bile-Blood Fistula: A Complication of Percutaneous Transhepatic Cholangiography

Abstract

BILE-BLOOD fistula during percutaneous transhepatic cholangiography has received only passing mention in the literature (4, 6, 12). Yet this grave complication may be expected in any large series. In our series of 20 studies, one patient, the subject of the present case report, experienced shock following the procedure. We attributed this result to a transient bile-blood fistula. Case Report An 81-year-old man was admitted to the San Francisco General Hospital with pain in the lower abdomen and tenderness in the right upper quadrant associated with chills and fever. A chronic obstructive uropathy with urinary infection was known to be present, and treatment with Keflin was instituted on admission. The serum bilirubin fell from 4.9 mg/l00 ml on admission to 2.5 mg/100 ml on the fourth day. On the fifth day a fever of 103° developed with a rise of bilirubin to 3.1 mg/100 ml, and Chloromycetin was added to the antibiotic treatment. The next day the bilirubin rose to 6.2 mg/100 ml. An upper gastrointestinal series was interpreted as normal. Seven days after admission percutaneous transhepatic cholangiography was performed through a right midaxillary approach under local anesthetic. Apolyethylene catheter (0.065 inches in diameter) was used with a No. 20 spinal needle as the rigid stylet. Light-green opalescent bile flowedfreely on withdrawal of the stylet after the first pass. Before the flow became sluggish 20 ml of bile was aspirated. Next, 30 ml of 50 per cent Hypaque was injected. Roentgenograms showed complete obstruction of the common duct, appearing typical of that caused by stone (Fig. I). Aspiration of the catheter after roentgenography failed to produce flow and the catheter was withdrawn. No blood was aspirated during the procedure. About twenty minutes after the procedure the patient suddenly became hypotensive and blood pressure fell to 60/0. Shaking chills and extreme vasoconstriction of the extremities were associated. Immediate treatment consisted of 2 1 of lactated Ringer's solution given rapidly and I g of Chloromycetin; both were administered intravenously. The blood pressure, sensorium, and general clinical condition improved rapidly. One hour later laparotomy disclosed a chronically infected gallbladder which was removed. A large stone was removed from the lower common duct and a T-tube was inserted. The patient responded well postoperatively. Bilirubin drawn twelv e hours after laparotomy was 9.5 mg/100 ml. This remained between 9 and 7 mg/100 ml during the first three postoperative days; then it fell slowly to normal. Aerobic culture of the bile aspirated during the cholangiography produced "moderate" growth of E. coli. The cytologic examination was reported as showing "many polymorphonuclear leukocytes." The patient was discharged in good condition.