Traumatic bilothorax following right thoracoabdominal gunshot injury: a case report of stepwise endoscopic and surgical management

Bilothorax, defined as the presence of bile in the pleural space, is an exceptionally rare cause of exudative effusion, usually related to hepatobiliary surgery or interventions. Post-traumatic bilothorax after gunshot injury is particularly uncommon and may be overlooked, leading to preventable pleuropulmonary morbidity. We report a 33-year-old man who sustained a right thoracoabdominal gunshot wound with lung, diaphragmatic, and hepatic injuries requiring emergency thoracotomy, diaphragmatic repair, and perihepatic packing. After initial stabilisation and drain removal, he re-presented with fever, dyspnea, and pleuritic chest pain. Imaging showed recurrent right pleural effusion, and dark, thick fluid was obtained on thoracentesis. Pleural fluid bilirubin measured 15.5 mg/dL with normal serum liver tests, confirming bilothorax. ERCP showed no distal obstruction; sphincterotomy and biliary stenting were performed, yet high-output bilious drainage persisted. Persistent bilothorax reflected a high-grade thoracobiliary fistula caused by a missile tract crossing the right lung, diaphragm, and liver. The prolonged presence of bile in the pleural space led to infected bilothorax and a thick pleural peel, illustrating the toxic and pro-inflammatory effects of bile on pleura and lung and the limitations of conservative and endoscopic management alone. Redo thoracotomy with decortication, repair of a 7–10 mm diaphragmatic defect, and subdiaphragmatic biliary drainage ultimately achieved resolution and full lung re-expansion. This case underscores the need for early suspicion of bilothorax after right thoracoabdominal trauma and supports a stepwise but timely escalation from drainage and ERCP to definitive surgical repair when high-output bile leak persists.