University of Nevada, Las Vegas School of Medicine Las Vegas, NV, United States
Kyaw Min Tun, DO1, Jose Aponte-Pieras, MD2, Katerina Roma, DO2, KaChon Lei, MD2, Bhavana Bhaya, MD3 1University of Nevada, Las Vegas School of Medicine, Las Vegas, NV; 2University of Nevada School of Medicine, Las Vegas, NV; 3VA Southern Nevada Healthcare System, North Las Vegas, NV
Introduction: Cholecystectomy can have complications such as gallbladder perforation, bile duct injury, bile leaks, and hemorrhage. Gallstone spillage is seen in 0.2 to 20% of cases with gallbladder perforation. Intrathoracic gallstones have been described in cases of open cholecystectomy presenting as hemoptysis. Pneumoperitoneum and intraoperative irrigation during laparoscopic cholecystectomy allows gallstones to migrate to the pleural space causing cholelithoptysis. Symptoms can appear several months or years after the procedure. A rarer complication from either open or laparoscopic cholecystectomy is fistula formation between biliary system and bronchopulmonary organs or pleural space. The fistula is formed when a gallstone is “dropped” intraoperatively eroding through the hemidiaphragm into the pulmonary space leading to complications such as cavity or abscess formation. Stones are commonly found in right lower lobe (RLL), or in some cases, right middle lobe.
Case Description/Methods: A 90-year-old male with history of cholecystectomy, Parkinson’s disease, and extensive cardiac history presented with gangrene of right third toe requiring amputation. Hospital course was complicated by an episode of hemoptysis. CT angiogram with contrast of thorax was unrevealing for pulmonary embolism; however it showed cavitation at RLL inseparable from the right hemidiaphragm and liver dome. Ill-defined hyper-attenuating structures within the cavity were suggestive of displaced gallstones that were also noted on a chest CT from 3 years ago. The gallstones likely eroded via the hemidiaphragm leading to fistulization between the hepatobiliary and pulmonary systems. Although operative reports for the prior cholecystectomy were not available, based on the clinical data available an open cholecystectomy was suspected to have been performed. Surgery was not offered for the pleuro-biliary fistula as patient was a poor surgical candidate due to his comorbidities. No further episodes of hemoptysis were noted and he was continued on intravenous vancomycin for MRSA bacteremia.
Discussion: This case highlights a rare complication of cholecystectomy that has been sparsely documented in literature. Placing the excised gallbladder into a retrieval bag prior to removal can reduce risk of gallstone spillage. The possibility of gallstones should be entertained in patients with history of biliary procedures and the chronic presence of intrapulmonary hyper-attenuating structures and inflammation, especially in RLL.
Figure: Figure: A panel of CT images of the thorax showed cavitation at right lower lobe of the lungs that is inseparable from the hemidiaphragm and liver dome as well as hyper-attenuating structures within the RLL cavity suggestive of gallstones.
Disclosures: Kyaw Min Tun indicated no relevant financial relationships. Jose Aponte-Pieras indicated no relevant financial relationships. Katerina Roma indicated no relevant financial relationships. KaChon Lei indicated no relevant financial relationships. Bhavana Bhaya indicated no relevant financial relationships.
Kyaw Min Tun, DO1, Jose Aponte-Pieras, MD2, Katerina Roma, DO2, KaChon Lei, MD2, Bhavana Bhaya, MD3. P0050 - A Case of Pleuro-Biliary Fistula Formation and Intrapulmonary Gallstones Due to Complication From Prior Cholecystectomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.