Introduction: Bilothorax is a rare condition defined by the presence of bile in pleural space. Notable causes are traumatic injury followed by hepatobiliary procedures. However, secondary to subphrenic/hepatic abscess, biliary obstruction is rare.
Case description: A 60-year-old female presented with abdominal pain and discomfort, fever, right-sided chest pain, dyspnea, and dry cough for 10 days. On examination, absent breath sounds on the right side of the chest with right hypochondrial tenderness. Ultrasound-guided diagnostic thoracocentesis showed exudative bilious pleural effusion with pleural fluid to serum bilirubin ratio above 1. Contrast-enhanced computed tomography (CECT) chest and abdomen reported right hydropneumothorax with empyema gallbladder, and dilated common bile duct (CBD) due to distal CBD stricture. The patient was managed with intravenous (IV) fluids, antibiotics, tube thoracostomy, and supportives. The patient was referred to the Department of Gastroenterology for which they advised surgical intervention.
Discussion: There are several possibilities of how bile travels into the pleural space, which includes the passive movement of bile through the diaphragm/lymphatic channels, traumatic or congenital defects in the diaphragm, and bilious fistulas. Other possible etiologies include the extension of biliary peritonitis, blunt trauma causing biliopleural fistula, or complication of open or percutaneous hepatobiliary procedures. The most specific test for diagnosis of bilothorax is the pleural fluid to serum bilirubin ratio.
Conclusion: Bilothorax is a rare manifestation. Unlike common etiologies of bilothorax such as trauma, and rupture of hepatic or subphrenic abscess, exclusively biliary tract obstruction due to CBD stricture is one rare possibility of bilothorax to be considered. Early diagnosis and treatment should be given to prevent the development of empyema as bile in enclosed areas is a good medium for the growth of bacteria. The linchpin management of bilothorax includes complete pleural drainage and correction of the root cause.
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