Case Presentation: A 73 year old female with a PMH of CKD 3a, GERD, and laryngeal cancer s/p total laryngectomy presented with epigastric pain for one day, radiating to bilateral upper abdominal quadrants, nausea, and vomiting.On exam the patient was hypertensive (240/90s), but otherwise hemodynamically stable. Lab work was unremarkable. A HIDA scan showed acute cholecystitis. The patient then underwent a laparoscopic partial cholecystectomy complicated by the need for open surgery, unclipped cystic duct, and hepatic capsule tearing. Therefore, a drain in the gallbladder fossa, and a hepatic duct stent were placed. Following drain removal, she developed increasing RUQ pain, CT abdomen showed a subcapsular fluid collection of 5.9×3.1cm. Subsequently a new gallbladder fossa drain was placed, and fluid was sent for analysis which then grew VRE and Candida Albicans. Then, based on susceptibilities, started on daptomycin, ceftriaxone, metronidazole, and fluconazole with six weeks of planned therapy.On POD:14, another CT chest/abdomen was performed for increasing, pleuritic RUQ pain which showed a right pleural effusion and translocation of the biliary stent. Thoracentesis pulled 620mL of exudative orange fluid. Pleural/serum total bilirubin ratio was 1.33. Fluid cultures were negative and cytology analysis showed benign, mixed inflammatory cells. Repeat ERCP was done for stent removal and new stent placement in the left and right hepatic ducts. Due to failure of repeat thoracenteses to clear the effusion, a thoracostomy tube was placed with gradually decreasing drainage before being pulled on POD:34. The patient was later discharged with plans for continued antibiotics, and outpatient drain removal/repeat ERCP.

Discussion: Bilothorax remains a rare cause of pleural effusion. Bilothoraces are typically a result of bile tract injury with fistulization to the pleural space, abscess formation near the diaphragmatic surface, or biliary obstruction [1-3]. Also, a bilothorax can be due to iatrogenic causes like hepatobiliary drain insertion. Finally, any biliary infection and inflammation may cause trans-phrenic movement of bile[4-17]. Due bile’s composite bile salts and alkalinity, bilothoraces are very irritating to the pleura resulting in inflammation and constant, pleuritic RUQ pain. Furthermore, due to nutrient availability in bile, bilothoraces often serve as media for bacterial infection from GI tract organisms. This propensity to infection has resulted in a strong association between bilothoraces and empyemas [3]. Yet, this is not always seen as with our patient where VRE was found in hepatic fluid, but not in pleural studies.Diagnosis of bilothorax is typically made within an overall clinical context. While imaging is often used, thoracentesis and fluid analysis are the most specific tests. Pleural fluid to serum bilirubin ratio of >1.0 is highly specific for bilothorax [3]. Management includes judicious antimicrobials and treatment of any underlying hepato-biliary or diaphragmatic pathology.

Conclusions: Bilothorax is a rare complication of cholecystectomy that requires urgent attention to prevent further complications. Pleural to serum bilirubin ratio greater than 1.0 is the most specific finding [3]. Treatment involves antimicrobials and correction of underlying causes. In our case, the patient had a partial cholecystectomy with several hepatobiliary complications. Prompt diagnostics and treatment of the bilothorax likely spared the patient from infectious sequela.