Case history: We present the case of a 44-year-old patient, admitted to the Intensive Medicine Unit of another institution due to severe alcoholic acute pancreatitis with organ failure. Due to right pleural effusion the patient underwent placement of a chest tube, with only an initial amount of hematic fluid being recovered. The pleural effusion persisted and imaging control confirmed its intrahepatic placement. At this stage, the patient is transferred to our center.

Clinical findings: Persistent pleural effusion

Results: Thoraco-abdominal CT confirmed that the drain had a descending path, transversing the right hemiliver (segments 6 and 7), with the extremity immediately lateral to the retrohepatic inferior vena cava. We opted for conservative management, with stepwise mobilization of the drain, (3 centimeters a day) and follow-up imaging. After 4 days the drain was removed with no bleeding or biliary fistula and no need for surgical intervention or angioembolization.

Diagnosis: Intrahepatic drain

Therapy and Progressions: We opted for conservative management, with stepwise mobilization of the drain, (3 centimeters a day) and follow-up imaging. After 4 days the drain was removed with no bleeding or biliary fistula and no need for surgical intervention or angioembolization.

Comments: Immediate hematic drainage in a supposedly serous pleural effusion and hemodynamic instability after chest tube placement on the right, should raise the suspicion of liver injury. The most severe consequence is uncontrolled bleeding, which may require operative management or angioembolization. In the case we report the drain was safely removed from inside the liver parenchyma without need for further intervention. This complication, rarely described in the literature, is avoidable with the use of proper technique.

References: 1.Collop NA, Kim S, Sahn SA. Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital. Chest 1997;112:709–13.

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