The Indian Journal of Chest Diseases and Allied Sciences

Register      Login

VOLUME 65 , ISSUE 2 ( April-June, 2023 ) > List of Articles


Bilothorax—An Unusual Presentation of Biliary Tract Obstruction: A Rare Case

S. Raghu, Dimple Nikhita Avanigadda, Ranjit Basha Pinjari, Balamani Ratnam Dollu, Thanuja Sri Vushakoyala, Siddhavali Chagalamarrai, Uthara Natarajan, Kalaivani Shanmuganandavadivel

Keywords : Biliary obstruction, Biliopleural fistula, Bilothorax, Case report, Chest and abdomen tube thoracostomy, Contrast-enhanced computed tomography empyema, Endoscopic retrograde cholangiopancreaticography, Transhepatic drainage

Citation Information : Raghu S, Avanigadda DN, Pinjari RB, Dollu BR, Vushakoyala TS, Chagalamarrai S, Natarajan U, Shanmuganandavadivel K. Bilothorax—An Unusual Presentation of Biliary Tract Obstruction: A Rare Case. Indian J Chest Dis Allied Sci 2023; 65 (2):59-62.

DOI: 10.5005/jp-journals-11007-0074

License: CC BY-NC 4.0

Published Online: 01-11-2023

Copyright Statement:  Copyright © 2023; The Author(s).


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.

PDF Share
  1. Dasmahapatra HK, Pepper JR. Broncho–pleuro–biliary fistula: A complication of intrahepatic biliary stent migration. Chest 1988;94:874–875. DOI: 10.1378/chest.94.4.874.
  2. Herschman Z, Amin D, Lehrfield A. Bilious pleural effusion as a complication of attempted percutaneous biliary drainage. Crit Care Med 1991;19:128–129. DOI: 10.1097/00003246-199101000-00035.
  3. Pisani RJ, Zeller FA. Bilious pleural effusion following liver biopsy. Chest 1990;98:1535–1537. DOI: 10.1378/chest.98.6.1535.
  4. Austin A, Fox N, Huggins J, et al. The green pleural effusion: A comprehensive review of the bilothorax with case series. Pleura 2017;4:21–31. Avaiable at:
  5. Basu S, Bhadani S, Shukla VK. A dangerous pleural effusion. Ann R Coll Surg Engl 2010;92(5):W53–W54. DOI: 10.1308/147870810X12699662980637.
  6. Jenkinson MR, Campbell W, Taylor MA. Bilothorax as a rare sign of intraabdominal bile leak in a patient without peritonitis. Ann R Coll Surg Engl 2013;95(7):118–119. DOI: 10.1308/003588413X13629960047678.
  7. Ferguson TB, Burford TH. Pleurobiliary and bronchobiliary fistulas. Surgical management. Arch Surg 1967;95(3):380. DOI: 10.1001/archsurg.1967.01330150056009.
  8. Dosik MH. Bile pleuritis: Another complication of percutaneous liver biopsy. Am J Dig Dis 1975;20(1):91. DOI: 10.1007/BF01073138.
  9. Oparah SS, Mandal AK. Traumatic thoracobiliary (pleurobiliary and bronchobiliary) fistulas: Clinical and review study. J Trauma 1978;18(7):539. DOI: 10.1097/00005373-197807000-00009.
  10. Strange E, Allen ML, Freedland PN, et al. Pleural fistula as a complication of percutaneous biliary drainage: Experimental evidence for pleural inflammation. The Am Rev Respir Dis 1988;137:959–961. DOI: 10.1164/ajrccm/137.4.959.
  11. Turkington RC, Leggett JJ, Hurwitz J, et al. Cholethorax following percutaneous transhepatic biliary drainage. Ulster Med J 2007;76(2):112. PMID: 17476828.
  12. Frampton AE, Williams A, Wilkerson PM, et al. Thoracobilia: A rare complication of gallstone disease. Ann R Coll Surg Engl 2010;92(5):W1–W3. DOI: 10.1308/147870810X12659688851951.
  13. Williams SW, Majewski PL, Norris JEC, et al. Biliary decompression in the treatment of bilothorax. Am J Surg 1971;122(6):829–831. DOI: 10.1016/0002-9610(71)90456-9.
  14. Addas RA, Al-Sabban AM, Fallatah AA, et al. Bilothorax a rare incidence in thoracic surgery: Case report and literature review. Open J Thorac Sur 2021;11(3):76–82. DOI: 10.4236/ojts.2021.113010.
  15. Tchercanskya AN, Alberti JF, Panzardi N, et al. Thoracic empyema after gallstone spillage in times of COVID. Int J Surg Case Rep 2020;76:221–226. DOI: 10.1016/j.ijscr.2020.09.181.
  16. Reddy VD, Al-Khateeb A, Hussain M, et al. Case report: Kryptonite— A rare case of left-sided bilothorax in a sickle cell patient. 2019;2019: 8658343. DOI: 10.1155/2019/8658343.
  17. Sano A, Yotsumoto T. Bilothorax as a complication of percutaneous transhepatic biliary drainage. Asian Cardiovasc Thorac Ann 2016:24(1):101–103. DOI: 10.1177/0218492315603214.
  18. Owens WB, Sanders, M.B. Spontaneous left-sided cholethorax. PulmCCM Journal 2015;1.
  19. Kim SH, Zangan SM. Percutaneous transhepatic biliary drainage complicated by bilothorax. Seminars in interventional radiology 2015;32(1):54–56. DOI: 10.1055/s-0034-1396965.
  20. Bilal M, Chong J, Lega M. Education and imaging. Hepatology: Bilothorax after percutaneous transhepatic biliary drainage. J Gastroenterol Hepatol 2015;30(5):802. DOI: 10.1111/jgh.12927.
  21. Bulus H, Aydin A, Koyuncu A, et al. Biliopleural fistula of a large retroperitoneal hydatid cyst. Turk J Gastroenterol 2015;26(3):284–285. DOI: 10.5152/tjg.2015.3610.
  22. Truong V, Huaringa A. Infected Biled In the Bellows: A Case of Pyocholethorax. The Internet Journal of Pulmonary Medicine 2013; Volume 15 Number 1.
  23. Cooper Z, Gupta A, Odom SR. Conservative management of a bilothorax resulting from blunt hepatic trauma. Ann Thorac Surg 2012;93(6):2043–2044. DOI: 10.1016/j.athoracsur.2011.11.024.
  24. Motika CA. A 66-Year-Old Man with cryptogenic cirrhosis and hepatocellular carcinoma with a bilious pleural effusion [abstract]. Chest 2008;134:c59001.
  25. Petri CR, Majid A, Anandaiah A. A Man with Biliary Sepsis and an Enlarging Pleural Effusion. Ann Am Thorac Soc 2019;16(4):496–498. DOI: 10.1513/AnnalsATS.201809-622CC.
  26. Cunningham LW, Grobman M, Paz HL, et al. Cholecystopleural fistula with cholelithiasis presenting as a right pleural effusion. Chest 1990;97(3):751–752. DOI: 10.1378/chest.97.3.751.
  27. Dahiya D, Kaman L, Behera A. Biliopleural fistula following gun shot injury in right axilla. BMJ Case Rep 2015;2015:bcr2014207454. DOI: 10.1136/bcr-2014-207454.
  28. Prabhu R, Bavara C, Purandare H, et al. Pleuro–biliary fistula: A delayed complication following open cholecystectomy. Indian J Gastroenterol 2005;24(1):28–29. PMID: 15778527.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.