Bilioptysis due to a single transcavitary thoracoabdominal gunshot wound

Correspondence to Dr David Gomez, St. Michael’s Hospital, Toronto, ON M5B1W8, Canada; david.gomez@unityhealth.to Case summary A 27-year-old man was transported to our trauma center after sustaining a single gunshot wound. Discussion Fistulization between the biliary system and the thoracic cavity is a rare condition that has been observed as a result of hepatic abscesses, pancreatitis, choledocholithiasis, neoplasms, iatrogenic injuries, and in rare circumstances trauma.1 Infrequently, this process results in a direct connection from the biliary tract to the bronchial tree, referred to as bronchobiliary fistula (BBF).1–3 Post-traumatic BBFs are extremely rare but have been noted to be more common in penetrating than blunt trauma.1 3 Several factors likely contribute to BBF formation in trauma, including untreated diaphragmatic lacerations and inadequate drainage of liver injuries.4 5 Patients with BBF characteristically present with fever, cough, and bilioptysis, which is pathognomonic of the disease.1 Secondary complications such as bronchiolitis, pneumonia, and respiratory failure are also common.1 Various diagnostic modalities can be useful for diagnosing BBF, including CT, MRCP, ERCP, and scintigraphy.6 7 ERCP is particularly effective at localizing the fistulous tract and allows for simultaneous therapeutic intervention.6 Interestingly, it has also been shown that the use of urine dipsticks to detect bilirubin in sputum may aid in making the diagnosis.8 An initial course of non-operative management appears appropriate in clinically stable patients, and typically includes pleural and perihepatic drainage, endoscopic or percutaneous biliary drainage, and administration of a somatostatin analogue.1 2 9–12 When necessary, there is some consensus that the best operative approach is via thoracotomy, which facilitates the release of lung entrapment, fistula excision, decortication, and diaphragmatic closure.5 13–16 The method of diaphragmatic repair is controversial but includes primary closure with or without coverage with acellular dermal matrices or a vascularized tissue pedicle.14 16 Conclusion BBF is rarely encountered, and important questions remain regarding its management. Communication was attempted both through his available contact information and family members. Ethics approval This submission was completed following appropriate ethics approval through the Research and Ethics Board of Unity Health Toronto.