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Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report
Jun Sunny Yin1, Shaylan Govind1, Daniele Wiseman2
1Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
Background:
Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature.
Case Presentation:
A 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen revealed a decompressed hepatic abscess extending into the right pleural space and the right lower lobe. A sigmoid-rectal fistula was also revealed with focal colonic thickening, presumed to be the sequelae of remote or chronic diverticulitis. An interventional radiologist inserted a percutaneous drain into the decompressed hepatic abscess and the instillation of contrast revealed immediate filling of the right pleural space, lung parenchyma, and bronchial tree, confirming a hepato-bronchial fistula. After two concurrent chest tube insertions failed to drain the remaining pleural effusion completely, surgical lung decortication was conducted. Markedly thickened pleura were seen and a significant amount of gelatinous inflammatory material was debrided from the lower thoracic cavity. He recovered well and was discharged 10 days post-thoracotomy on oral antibiotics. The percutaneous liver abscess tube was removed 3 weeks post-discharge from hospital after the drain check revealed that the fistula and abscess had entirely resolved.
Conclusions:
Refractory right-sided pleural effusion combined with constitutional symptoms should alert clinicians to search for possible hepatic abscess, especially in the context of diverticulitis. The rupture of an untreated hepatic abscess could lead to death from profound sepsis or rarely, as in this case, a hepato-bronchial fistula. Timely investigation and a multidisciplinary treatment approach can lead to improved patient outcomes.
Insights
Diverticulitis can lead to hepatic abscesses, which rarely can progress to a hepato-bronchial fistula. This case highlights the importance of investigating pleural effusions for underlying hepatic abscesses in diverticulitis patients.
Area of Science:
- Gastroenterology
- Pulmonology
- Infectious Disease
Background:
- Diverticulitis predisposes patients to hepatic abscesses through portal circulation seeding.
- Hepatic abscesses are known complications of diverticulitis, but progression to hepato-bronchial fistulization is exceptionally rare.
Observation:
- A 61-year-old male with a history of diverticulitis presented with weight loss and dyspnea.
- Imaging revealed a hepatic abscess extending into the pleural space and lung, with a confirmed hepato-bronchial fistula.
- The patient also had a sigmoid-rectal fistula, presumed secondary to chronic diverticulitis.
Findings:
- Percutaneous drainage of the hepatic abscess confirmed the hepato-bronchial fistula.
- Surgical lung decortication was required to manage the complex pleural effusion.
- The patient recovered with a multidisciplinary approach involving percutaneous drainage and surgery.
Implications:
- Refractory pleural effusions with constitutional symptoms warrant investigation for hepatic abscess, particularly in patients with diverticulitis.
- Untreated hepatic abscess rupture can cause sepsis or rare fistulization.
- Prompt diagnosis and integrated treatment strategies are crucial for favorable patient outcomes.