(1159) Bronchobiliary Fistula Masquerading as Pneumonia

Introduction: Bronchobiliary fistula secondary to bile duct obstruction by gallstone can present with clinical and radiographic features of pneumonia. Bilioptysis is pathognomonic but may be mistaken for purulent sputum. Biliary drainage with treatment of underlying gallstone disease usually results in remission.

Description: A 45 year-old male with past history of gallstone pancreatitis complicated by pseudocyst with common bile duct obstruction status post endoscopic cyst gastrostomy, and endoscopic retrograde cholangiopancreaticography (ERCP) with common bile duct (CBD) stenting presented with fever, cough with yellowish phlegm and dyspnea. Physical examination showed tachypnea and low oxygen saturation. He was placed on high flow nasal cannula (HFNC) but due to worsening hypoxia, he required intubation and mechanical ventilation. Leukocytosis was present. Bilirubin level was normal. CT scan of chest showed multilobar pneumonia with consolidation of right middle and lower lobes. Treatment for pneumonia was initiated with broad spectrum antibiotics. Endotracheal airway suctioning showed traces of bile. Sputum analysis confirmed bilioptysis. Bronchoscopy revealed copious bilious secretion in the right and left main bronchus. CT scan of the abdomen with contrast revealed dilated common bile duct, intrahepatic biliary dilatation and distended gallbladder with a 1.5 cm stone in the neck. Hepatobiliary iminodiacetic acid (HIDA) scan showed extravastion of tracer into the right chest. He subsequently underwent ERCP with sphincterotomy, stone removal and placement of biliary stent to relieve the fistula. Percutaneous cholecystostomy placement was done. This was followed by improvement of his clinical status and white cell count. He was discharged with cholecystostomy drain. He underwent elective interval laparoscopic cholecystectomy 12 weeks later. He had no recurrence of symptoms in the following 6 months.

Discussion: The diagnosis of bronchobiliary fistula can be challenging. The clinical features, lab parameters and radiological picture may resemble pneumonia. A high degree of suspicion is required for patients who have had gallstone disease and previous hepatobiliary surgery. Identifying bile in the sputum is pathognomonic. Our experience can aid physicians in the diagnosis of bronchobiliary fistula.