Biliary Breach: A Rare Case of a Biliary Pleural Fistula Without a History of Trauma.

Biliary pleural fistulas (BPFs) are pathologic connections between the biliary tree and pleural cavity, allowing for abnormal flow of bile into the pleural space. This finding is rare and typically results from surgical procedures, such as chest tube placement, or trauma. We present the case of an 84-year-old male who initially presented with respiratory and gastrointestinal symptoms. Non-contrast CT of the chest, abdomen, and pelvis demonstrated a large right-sided empyema, which appeared to be continuous with a fluid-containing structure in the gallbladder fossa. Subsequent diagnostic workup revealed a biliary pleural fistula, which was ultimately treated with robotic cholecystectomy and fistula takedown. BPFs are rare entities; however, clinicians should consider them in the differential diagnoses of patients who present with both gastrointestinal and respiratory symptoms.