(1453) A Green Surprise: Bilious Pleural Fluid Secondary to Esophageal Rupture: A Case Report

Introduction: Bilothorax, an exudative pleural effusion due to the accumulation of bile was first reported in 1971. Here, we report a rare case of bilateral bilothorax and septic shock due to esophageal rupture.

Description: 78-year-old man with multiple medical ailments presented with a severe episode of vomiting accompanied with a popping sound, respiratory distress, and right sided chest pain. Patient had tachycardia, BP of 101/89 mm Hg, and tachypneic. CT scan of the chest and abdomen revealed air adjacent to the esophagus suggesting perforation, atelectasis of right lung, bilateral pleural effusion (R>L), and gallbladder hydrops. However, an esophagram did not reveal any perforation. Right-sided chest tube drained dark green bilious fluid. Symptoms worsened and patient was hypotensive, tachycardic, tachypneic, and hypoxemic. He was intubated with fluid and vasopressor support. Diagnosis of hypoxemic respiratory failure and septic shock following distal esophageal perforation and bilateral bilothorax was made. Cultures were drawn and empiric therapy of cefepime and vancomycin were started. Nuclear hepatobiliary scan (HIDA) was performed to rule out hepatobiliary fistula. Results showed reflux activity into the stomach and distal esophageal leak was identified. Gastrojejunal stenting was performed and the patient regained normal breathing in 5 days and was subsequently discharged.

Discussion: Sudden increase in intraesophageal pressure and negative intrathoracic pressure which occurs during severe retching results in esophageal rupture, leading to mediastinitis, pleural collections, and sepsis. Fistulas can be identified using CT scans a few days after, between the abdominal and chest cavities. Esophagography with contrast medium can detect a perforation. However, Gastrografin swallow has high false-negativity (70%). This is due to the timing of examination, technique, or the inferior radiographic detail provided by the contrast. The use of barium sulfate is considered to result in higher sensitivity when compared to those utilizing water-soluble agents (Gastrografin/diatrizoate). Additionally, HIDA scan can be utilized to visualize anatomical defects. Bilateral biliary pleural effusion following an esophageal rupture is an rare presentation that requires aggressive management.