International Journal of Clinical & Medical Images

A 55 year old gentleman underwent an ultrasound-guided tube thoracostomy for a right-sided massive pleural effusion (Figure 1). The chest drain revealed yellow-particulate fluid, raising the suspicion of an oesophageal perforation, owing to the history of multiple failed endoscopic retrograde cholangio-pancreatograms. On reviewing the patient’s clinical notes and scans, it was found that the patient had undergone a percutaneous transhepatic cholangiogram (PTC) with insertion of an internal/external drain, ten days prior to clinical worsening (Figure 2). A “check” chest x-ray post-PTC had been done (Figure 3). The tip of the right costo-phrenic angle had been pierced by the catheter. This was missed on radiological and clinical reviewing. This case emphasises the importance of critically assessing the patient by, both, clinical evaluation and supplementary radiological corroboration. This was a missed diagnosis of a rare encounter of an iatrogenic pleurobiliary fistula.