Pulmonary and Critical Care Medicine Attending William Beaumont Army Medical Center, United States
Introduction: Percutaneous transhepatic biliary drains are used to relieve biliary obstruction. High output from biliary drains can cause hyponatremia, metabolic acidosis, malabsorption, diarrhea, and hypovolemia. We describe a patient with intrahepatic cholangiocarcinoma and biliary obstruction with high output biliary drains who presented with hypovolemic shock and was treated with palliative bile refeeding to allow the patient to discharge home.
Description: A 69-year-old male with intrahepatic cholangiocarcinoma and biliary obstruction with two biliary drains presented with headache, presyncope, shortness of breath, chest pain, and initial BP of 51/43. The patient was admitted for undifferentiated shock with myocardial ischemia and acute kidney injury and resuscitated with intravenous fluids and vasopressors. Admission laboratory results showed hyponatremia, metabolic acidosis, and hyperbilirubinemia. The biliary drains were patent and high output was recorded. Biliary losses were replaced with intravenous fluids including sodium bicarbonate. Hyponatremia and metabolic acidosis rapidly improved, but the patient required continued intravenous infusion for sustained improvement. His stools remained pale. Intravenous fluids were discontinued, and oral fluids were encouraged, but recurrent hypotension prevented discharge. The patient was not a candidate for biliary stenting due to distribution of tumor, so palliative bile refeeding was proposed. The patient refused a nasogastric tube but was amenable to a gastrostomy tube. Biliary drain output was manually refed via a syringe after each meal into the gastrostomy tube, improving his hyponatremia, metabolic acidosis, pale stools, and hypotension without further need for continued IV fluid infusions. He was discharged home to continue palliative bile refeeding.
Discussion: We describe palliative bile refeeding in a patient with malignant biliary obstruction and high output biliary drains who presented with hypovolemic shock and otherwise required regular intravenous fluids to prevent recurrent metabolic derangements, hypovolemia, and hypotension. Bile refeeding is an effective, low-cost, and physiologic treatment for biliary losses associated with metabolic derangements and hypovolemia that can be performed by patients at home.
