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Breathlessness after percutaneous biliary drainage

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A 77 year old woman presented with painless progressive jaundice and weight loss. She also had generalised pruritus and was passing dark urine and pale stools. On examination there was a palpable right upper quadrant abdominal mass. Plasma bilirubin level was 56 μmol/l and alkaline phosphatase was 350 U/l. Serum amylase was within normal limits. Abdominal ultrasound scan showed a dilated biliary tree and a distended gallbladder but there was no evidence of gallstones. Abdominal computed tomography was performed (fig 1). The patient underwent an endoscopic retrograde cholangiopancreaticogram (ERCP) and insertion of a biliary stent, with resolution of the jaundice.

Figure 1

Abdominal computed tomogram.

Ten days later the patient became jaundiced again and an abdominal ultrasound suggested stent occlusion with recurrent biliary tree dilatation. Percutaneous transhepatic cholangiography (PTC) with external biliary drainage was performed. The patient gradually became short of breath with right sided pleuritic pain and a thoracic radiograph was obtained (fig 2). Thoracocentesis was performed and the pleural aspirate is shown (fig3).

Figure 2

Thoracic radiograph.

Questions

(1)
What is the most likely cause of her jaundice and why was this suspected clinically?
(2)
What complication of PTC has occurred?
(3)
What is the treatment of this complication?

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