Minkyung Kwon

1118: A 72-YEAR-OLD MAN WITH PERSISTENT RIGHT UPPER QUADRANT PAIN AFTER ABDOMINAL SURGERY

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: We present a very interesting case of postoperative complication that required critical care. Methods: A 72-year-old male underwent ileal enterotomy after developing gallstone ileus and post-operatively developed a perihepatic abscess and choledochal fistula. A percutaneous drain was inserted for treatment. Two weeks later, he developed right upper quadrant abdominal pain and returned to the hospital. On exam, vital signs were normal and laboratory testing revealed anemia, leukocytosis, and hypokalemia. C-reactive protein was markedly elevated and a chest x-ray showed opacities in the right lung. An abdominal MRI was performed to visualize the hepatobiliary tree and showed multi-loculated air-fluid collections along the subdiaphragmatic surface of the liver; a small right pleural effusion was also visualized. A Sinogram was performed through previously placed drain and showed contrast extravasation across the diaphragm and into the distal and bronchi of the right lower lobe. Cultures from the biliary drain grew Enterococcus, H. influenzae, and alpha-streptococci. Ertapenem and vancomycin were started. CT scan of the chest showed worsening right lower lobe consolidation and the drainage tube terminating in the pleural space. Subsequent bronchoscopy showed purulent secretions in the right middle and lower lobes. Repeat sinogram demonstrated a fistulous connection between subhepatic space and pulmonary bronchi with new intraparenchymal abscess. Ultimately, he underwent thoracotomy with right lower and middle lobectomy, takedown of subphrenic abscess fistula, and laparotomy with drainage of the abscess. Results: A few cases of broncho-pleuro-peritoneal fistula have been reported. Most described cases have been associated with subphrenic infections resulting in diaphragmatic ruptures and subsequent fistula formation. Therapy is primarily surgical, in addition to the supportive measures to keep the peak airway pressure low, such as differential ventilation or high-frequency oscillatory ventilation. Severe broncho-pleuro-peritoneal fistula requires debridement of bronchopulmonary tissue, repair of diaphragmatic perforations, drainage of subphrenic abscesses, and antibiotic therapy.