Abstract Introduction Bronchopulmonary-hepatobiliary fistula is a rare complication of hepatobiliary disease involving an abnormal tract between the biliary system and lung. It can occur from infection, malignancy, trauma, or previous biliary procedures. Early recognition is important because delay in diagnosis can lead to severe infection, sepsis, or respiratory failure. Case Description A 64-year-old man with cirrhosis, hepatocellular carcinoma treated with Y-90 radioembolization, chronic cholecystitis status post cholecystostomy tube, chronic thrombocytopenia, and atrial fibrillation presented with several days of cough, fever, and worsening dyspnea. CT angiography of the chest showed multifocal necrotizing pneumonia without pulmonary embolism, and he was intubated for acute hypoxemic respiratory failure. Bilious secretions were seen in the endotracheal tube, raising suspicion for hepatopulmonary communication. Abdominal MRI demonstrated a tract connecting intrahepatic bile ducts to the right lower-lobe bronchus, confirming a bronchopulmonary-hepatobiliary fistula. Given his history of chronic cholecystitis and a retained biliary stent, he was transferred to a tertiary hepatobiliary center for further management. Endoscopic Retrograde Cholangiopancreatography (ERCP) showed an occluded plastic stent, which was replaced with a self-expanding metal stent terminating in the left hepatic duct to decompress the biliary system. Following the procedure, oxygenation improved and he was successfully extubated. Repeat imaging weeks later showed interval enlargement of a hepatobiliary-to-pulmonary abscess. Multidisciplinary review determined that surgery or drainage would carry high risk given his cirrhosis and frailty. He was managed conservatively with continued biliary drainage, ceftriaxone and metronidazole, and careful volume management. Despite stability, the abscess persisted. After a goals-of-care discussion, the patient chose comfort-focused management and was discharged to hospice care. Discussion Bronchopulmonary-hepatobiliary fistula is an uncommon and often underrecognized condition that can develop after prolonged biliary inflammation, infection, or prior procedures involving the bile ducts. The presence of bile in respiratory secretions, known as bilioptysis, is a key diagnostic sign but can be easily missed in intubated patients. Imaging studies such as MRI or MRCP typically identify the fistula, while ERCP confirms the diagnosis and allows for decompression of the biliary system. In patients with preserved liver function, a thoracobiliary fistulectomy can be curative. However, in those with decompensated cirrhosis or advanced malignancy, a non-surgical approach focused on biliary drainage, infection control, and comfort is often more appropriate. This case highlights the importance of recognizing bilioptysis early, utilizing minimally invasive options when possible, and tailoring management to the patient’s overall condition and goals of care. This abstract is funded by: None
Yousefzai et al. (Fri,) studied this question.