PMC6604467_01
Initial chest X-ray demonstrating an isolated left-sided pleural effusion.
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fig1
A chest X-ray revealed an isolated large left pleural effusion (Figure 1).
A thoracentesis yielded 900 cc of exudative bilious fluid.
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Thoracentesis was performed revealing 900 cc of green bilious-appearing fluid (Figure 2) with pleural fluid analysis (PFA) showing an elevated pleural bilirubin (3 mg/dL) to serum bilirubin (2.2 mg/dL) ratio greater than 1, confirming the diagnosis of an isolated left-sided bilothorax (Table 1).
Magnetic resonance cholangiopancreatography (MRCP) showing an acute angle in the mid-common bile duct with upstream dilatation.
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fig3
The distal CBD measured 8 mm (Figure 3).
Coronal image of an MRCP showing an isolated left intrahepatic duct extending through the left hepatic lobe to the left costophrenic angle.
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fig4
An isolated left intrahepatic duct was seen extending to the distal margin of the left hepatic lobe; however, no clear fistulous connection was seen with the left pleural space (Figure 4).
Endoscopic retrograde cholangiopancreatography (ERCP) fluoroscopic image showing dilated intrahepatic ducts with absence of filling on the common bile duct (evidenced by the guidewire).
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fig5
An endoscopic retrograde cholangiopancreatography (ERCP) showed prominent intrahepatic biliary ducts, however the mid-to-distal common bile duct was poorly visualized below the sharp angulation (Figure 5).