title: Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
authors.forename: Jun Sunny
authors.initials: JS
authors.lastname: Yin
authors.affiliation: Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
authors.forename: Shaylan
authors.initials: S
authors.lastname: Govind
authors.affiliation: Department of Medical Imaging, London Health Sciences Centre, University of Western Ontario, London, ON, Canada.
authors.forename: Daniele
authors.initials: D
authors.lastname: Wiseman
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, London Health Sciences Centre, University of Western Ontario, London, ON, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Inculet
authors.affiliation: Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada. raymond.kao@lhsc.on.ca.
authors.forename: Raymond
authors.initials: R
authors.lastname: Kao
mesh_terms: D001658:Biliary Fistula / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D001983:Bronchial Fistula / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D002404:Catheterization / Q000379:methods*; D012809:Colon, Sigmoid / Q000000981:diagnostic imaging / Q000473:pathology*; D004239:Diverticulitis, Colonic / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D004322:Drainage; D004417:Dyspnea / Q000209:etiology*; D006801:Humans; D008100:Liver Abscess / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D010996:Pleural Effusion / Q000000981:diagnostic imaging* / Q000503:physiopathology; D013902:Radiography, Thoracic; D013908:Thoracotomy; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D015431:Weight Loss
keywords: Case report; Diverticulitis; Hepatic abscess; Hepato-bronchial; fistula