Pulmonary bile emboli. Sequelae of iatrogenic trauma

A 58-year-old man manifested obstructive jaundice secondary to adenocarcinoma of the common hepatic duct. The markedly icteric patient underwent multiple diagnostic and therapeutic procedures, including percutaneous needle biopsy of the liver, curettage, catheterization and washing of the hepatic ducts, and percutaneous transhepatic cholangiography. Three months later the patient died of a bleeding gastric ulcer. Autopsy confirmed the presence of adenocarcinoma of the common hepatic duct. Microscopic examination of the lungs disclosed numerous bile emboli in the smaller arteries, arterioles, and in a few alveolar capillaries. Histochemical reaction of the emboli was positive for bilirubin. Organizing fibrin was seen around occasional bile emboli, but most were without microscopic reaction. Review of the literature disclosed nine cases of pulmonary bile embolism, six of which had a history of marked cholestasis and trauma to the liver, like the present patient. Bile reaches the systemic circulation through a biliary-venous fistula that, in our case, was probably iatrogenic.