Bilioptysis – Two Case Reports of Broncho Biliary Fistula

Bronchobiliary fistula (BBF) is a tract between the biliary system and bronchial tree with the presence of bile in the bronchus and the sputum. They are rare but serious complications. In most cases, they are caused by hepatic or subphrenic abscesses, resulting from different conditions. Pulmonary symptoms dominate the clinical picture, and the main manifestations are chronic irritant cough, production of greenish sputum, bronchopneumonia, and dyspnea. The diagnosis of BBF can be confirmed by imaging procedures such as biliary scintigraphy with hepatobiliary iminodiacetic acid, percutaneous transhepatic cholangiography, or endoscopic retrograde cholangiopancreatography. Bronchoscopy can demonstrate the presence of bile in the bronchial tree and may delineate the site of fistula. The treatment strategy for patients with BBF and biliary tract obstruction is the reestablishment of bile drainage, which allows the fistula to heal by reducing intrabiliary pressure. We present two cases of biliary-bronchial fistula, one related to hepatic abscess and the other due to percutaneous transhepatic biliary drainage for common bile duct obstruction secondary to inoperable hilar cholangiocarcinoma

Pancreatico‑pleural Fistula: Case Series

Pancreatico‑pleural fistula is a rare but serious complication of acute and chronic pancreatitis. The pleural effusion caused by pancreatico‑pleural fistula is usually massive and recurrent. It is predominately left‑sided but right‑sided and bilateral effusion does occur. We report four cases of pancreatico‑pleural fistula admitted to our hospital. Their clinical presentation and management aspects are discussed. Two patients were managed by pancreatic endotherapy and two patients were managed conservatively. All four patients improved symptomatically and were discharged and are on regular follow‑up. Most of these patients would be evaluated for their breathlessness and pleural effusion delaying the diagnosis of pancreatic pathology and management. Hence, earlier recognition and prompt treatment would help the patients to recover from their illnesses. Pancreatic pleural fistula diagnosis requires a high index of suspicion in patients presenting with chest symptoms or pleural effusion. Extremely high pleural fluid amylase levels are usual but not universally present. A chest X‑ray, pleural fluid analysis, and abdominal imaging (magnetic resonance cholangiopancreatography/magnetic resonance imaging abdomen more useful than contrast‑enhanced computed tomography abdomen) would clinch the diagnosis. Endoscopic retrograde cholangiopancreatography with stent or sphincterotomy should be considered when pancreatic duct (PD) reveals a stricture or when medical management fails in patients with dilated or irregular PD. Surgical intervention may be indicated in patients with complete disruption of PD or multiple strictures

Noninvasive Prediction of Large Esophageal Varices in Chronic Liver Disease Patients

<b>Background/Aim:</b> Esophageal varices (EVs) are a serious consequence of portal hypertension in patients with liver diseases. Several studies have evaluated possible noninvasive markers of EVs to reduce the number of unnecessary endoscopies in patients with cirrhosis but without varices. This prospective study was conducted to evaluate noninvasive predictors of large varices (LV). <b> Patients and Methods: </b> The study analyzed 106 patients with liver diseases from January 2007 to March 2008. Relevant clinical parameters assessed included Child-Pugh class, ascites and splenomegaly. Laboratory parameters like hemoglobin level, platelet count, prothrombin time, serum bilirubin, albumin and ultrasonographic characteristics like splenic size, splenic vein size, portal vein diameter were assessed. Univariate and multivariate analysis was done on the data for predictors of large EVs.<b> Results:</b> Incidence of large varices was seen in 41&#x0025;. On multivariate analysis, independent predictors for the presence of LV were palpable spleen, low platelet count, spleen size&#62; 13.8 mm, portal vein&#62; 13 mm, splenic vein&#62; 11.5 mm. The receiver operating characteristic (ROC) curve showed 0.883 area under curve. Platelet spleen diameter ratio 909 had a sensitivity and specificity of 88.5&#x0025;, 83&#x0025; respectively.<b> Conclusion: </b> Thrombocytopenia, large spleen size, portal vein size and platelet spleen diameter ratio strongly predicts large number of EVs