S5623 Post Orthotopic Liver Transplant Anastomotic Bile Leak Causing Bilothorax

Introduction: Pleural effusions are common after orthotopic liver transplantation, occurring in up to 95% of patients within the first postoperative week. Most are benign and resolve spontaneously. However, a persistent or complicated pleural effusion, particularly in the absence of pulmonary infection, warrants further evaluation. We present a rare case of bilothorax as a postoperative complication of liver transplant. Case Description/Methods: A 67-year-old man who received an orthotopic liver transplant (OLT) with extensive adhesiolysis, portal vein thrombectomy, and transdiaphragmatic right thoracentesis presented to the emergency department 3 months post transplant with symptomatic anemia with worsening lightheadedness, dyspnea, chills, and fatigue. Computed tomography angiography of the abdomen/pelvis demonstrated rim-enhancing fluid in the right lower chest, and a thoracostomy tube was placed on hospital day (HD) 1. Initial fluid studies showed a complicated exudative effusion. Cultures revealed Enterococcus faecium and Clostridium clostridioforme; appropriate antibiotics were initiated. The chest tube continued to have output of >150 cc. In the absence of a clear source of infection such as pneumonia, a pleural fluid-to-serum bilirubin ratio was obtained and found to be 1.6, indicative of bilothorax. Magnetic resonance cholangiopancreatography on HD5 showed discontinuity between the donor common bile duct (CBD) and native CBD, suggestive of high-grade anastomotic stricture. Percutaneous transhepatic cholangiogram performed on HD8 did not reveal stricture, but rather demonstrated delayed filling of the native CBD and anastomotic leak with a fistulous connection to the duodenum and superior extension suggestive of a pleurobiliary fistula. It was determined this was the most likely cause of the patient’s bilothorax. A 10 Fr internal/external biliary drain was placed through the native CBD. Discussion: Persistent pleural effusions, a common complication post OLT, are typically exudative by Light’s criteria. Bilothorax from a pleurobiliary fistula is a much rarer complication, with few cases documented in the literature. Imaging to assess biliary anastomotic patency and bilirubin pleural studies should be considered, particularly in patients with prior diaphragmatic manipulation.