Case of bilioptysis following hydatid cyst removal

Bilioptysis is a rare condition characterized by the presence of bile in the sputum, resulting from an abnormal fistulous connection between the biliary tree and the bronchus (biliobronchial fistula). Biliobronchial fistula is associated with high morbidity and mortality; hence, early diagnosis and timely treatment are crucial. We present a case of a 46-year-old male who presented with complaints of bilioptysis for 1 day. He had a history of a hydatid cyst of the liver, which was surgically treated 2 years ago. The patient subsequently developed recurrent fever and vomiting due to a persistent subdiaphragmatic collection. Multiple attempts to drain the abscess/collection were made using percutaneous drainage and endoscopic retrograde cholangio pancreatography (ERCP) with stenting to relieve intrahepatic biliary obstruction. Despite these interventions, the patient developed intrahepatic biliary radical (IHBRD) dilatation, which led to bile tracking through a diaphragmatic rent likely caused by percutaneous drain insertion, resulting in a fistulous connection with the right anterobasal and basolateral bronchial segments. A contrast computed tomography (CT) scan of the thorax and abdomen showed fistulous tract communication to lung parenchyma. He underwent an operative intervention, during which the fistulous tract was excised under intraoperative bronchoscopy guidance. This was followed by the excision of lung segments with a fistula and the repair of the diaphragmatic rent. ERCP and stenting were also done in the same sitting for source control. The patient was discharged with complete resolution of bilioptysis.