A Case of Biliary Fistula Diagnosed by Sonazoid-enhanced Ultrasonography

doi:10.21203/rs.3.rs-3087148/v1

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A Case of Biliary Fistula Diagnosed by Sonazoid-enhanced Ultrasonography

https://doi.org/10.21203/rs.3.rs-3087148/v1

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Our study presents a clinical case encompassing a 69-year-old female patient who received radiotherapy as a therapeutic intervention for an unresectable malignancy affecting the pancreas. Subsequent to an incident involving the dislodgement of the Percutaneous Transhepatic Cholangiography and Drainage (PTCD) tube during the patient's hospitalization, a successful ultrasonography-guided PTCD procedure was performed. Moreover, Sonazoid-enhanced ultrasonography, facilitated through the PTCD tube, was employed to ascertain the presence of a biliary fistula. The fistula was ultimately remedied through the timely implementation of ultrasound-guided abdominal drainage.

Conclusion: Sonazoid contrast-enhanced ultrasonic cholangiography conducted via a PTCD tube offers a convenient and secure modality for visualizing parameters such as fistula length, fistula width, and fractional flow.

Sonazoid

Ultrasonography

PTCD

Biliary fistula

The diagnosis of a biliary fistula represents a grave clinical complication that necessitates early recognition, a task often challenging with conventional ultrasound techniques. PTCD is a standard ultrasonographic intervention extensively employed in clinical settings. Opting for Sonazoid contrast-enhanced ultrasonic cholangiography via a PTCD tube holds potential in facilitating the diagnosis of biliary fistula, thereby offering valuable assistance in its management.

A 69-year-old female patient presented with symptoms of abdominal pain and distention, accompanied by the manifestation of jaundice evident in the yellowing of the skin and sclera, persisting for a duration of one month. Notably, the patient also exhibited a concurrent coexistence of congenital heart disease, specifically comprising atrial septal defect, left-to-right shunt at the atrial septum, right ventricular hypertrophy, right atrial enlargement, moderate tricuspid valve regurgitation, and pulmonary hypertension. The feasibility of administering general anesthesia for surgical resection was precluded by the anesthetic evaluation. Consequently, the patient underwent PTCD performed under local anesthesia to alleviate jaundice. Subsequently, the patient was transferred to the oncology department for radiotherapy.

During the patient's hospitalization, an inadvertent slip of the PTCD tube occurred, resulting in minimal discomfort, characterized only by mild abdominal pain. Two days later, an ultrasound-guided PTCD procedure was performed, revealing slight dilation of the intrahepatic bile duct and a small quantity of perihepatic fluid in the preoperative ultrasound assessment（Fig.1）. The Seldinger technique was employed to successfully puncture the left external lower branch bile duct, ensuring unobstructed drainage throughout the puncture process（Fig.2）. For contrast-enhanced ultrasonic cholangiography via the PTCD tube, 10 ml of Sonazoid solution (mixed at a 1:200 ratio with saline) was administered. The imaging displayed satisfactory visualization of the intrahepatic bile ducts（Fig.3）, wherein the contrast agent within the right hepatic duct leaked into the abdominal cavity via a long and slender duct, indicating the presence of a concurrent biliary fistula（Fig.4）. Furthermore, the perihepatic fluid was attributed to the biliary fistula. Consequently, immediate measures were taken to establish drainage for the perihepatic fluid, which exhibited characteristics resembling yellow bile. Following one week of treatment, the patient's abdominal pain resolved, and no fluid was drained from the perihepatic fluid drainage tube. Subsequent follow-up ultrasound examinations indicated the disappearance of perihepatic fluid, leading to the removal of the abdominal drainage tube. The treatment proved successful and timely, as the biliary fistula was promptly detected and drained through ultrasonography, thereby averting abdominal infection and creating favorable conditions for subsequent radiotherapy.

Sonazoid, a second-generation ultrasound contrast agent, has established its efficacy in liver lesion ultrasonography, primarily due to its distinctive Kupffer phase^[1]. Its robust shell structure enables it to withstand higher levels of ultrasound mechanical index, resulting in reduced microbubble rupture and enhanced contrast image quality^{[2, 3]}. PTCD is a widely utilized procedure for both diagnosis and treatment of biliary tract disorders. It offers advantages such as ease of operation and decreased exposure to ionizing radiation when compared to ultrasound guidance under X-ray guidance^[4]. Ductal ultrasonography performed via a PTCD tube provides valuable information regarding the location of the drainage duct, as well as the presence and severity of biliary strictures^[5]. Existing literature primarily focuses on Sonovue, with limited reports on the utilization of Sonazoid. Leveraging the benefits of Sonazoid and PTCD, we successfully conducted ultrasound-guided PTCD with the informed consent of the hospital ethics committee and the patient. This was followed by contrast-enhanced ultrasonic cholangiography via the PTCD tube, allowing for timely detection of the patient's concurrent biliary fistula while confirming the optimal positioning of the drainage ducts. Conventional grayscale ultrasound poses challenges in diagnosing biliary fistulas, with indirect signs such as ascites or peritonitis serving as mere indications ^[6]. We present this case to highlight the capacity of ultrasonography to provide precise insights into fistula length, width, and shunt flow, thereby establishing a reliable foundation for subsequent treatment steps.

Sonazoid contrast-enhanced ultrasonic cholangiography performed via a PTCD tube proves to be a secure, expedient, and efficacious approach for diagnosing biliary fistulas.

Ethics approval and consent to participate: All methods were carried out in accordance with relevant guidelines and regulations. All experimental methods were approved by Medical Ethics Committee of Mianyang Central Hospital. And Informed written consent was obtained from the patient for the publication of this report and any accompanying images.

Consent for publication: All the authors approved the publication of the manuscript in the Journal.

Availability of data and materials：This article can provide a good prompt for clinical practice, and also help sonographers to provide ideas for the diagnosis of bile leakage

Competing interests：The authors declare that they have no conflict of interest to disclose.
Funding：No funding.
Authors' contributions：Zhang Lei and Han Xiao-jun contributed to data curation and writing of the original draft; Han Xiao-jun contributed to data curation; Zhang Lei contributed to manuscript review and editing; all authors have read and approved the final manuscript.
Acknowledgement：Thank you to our hospital and department, as well as colleagues for their support.
Authors' information (optional)：
Zhang Lei : Doctor, Master student, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China,[email protected]

Han Xiao-jun: Doctor, Attending physician, Undergraduate, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000,China,[email protected]

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No competing interests reported.

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A Case of Biliary Fistula Diagnosed by Sonazoid-enhanced Ultrasonography

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