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

INTRODUCTION: 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. CASE PRESENTATION: 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. CASE DISCUSSION: 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. CONCLUSION: 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.