• biliary pleural fistula
• bilopleural fistula
• cholecystitis
• cholecystopleural fistula
• empyema

• Bilothorax
• Case report
• Cholethorax
• ERCP
• Thoracentesis
• Thoracobilia

The management of gallbladder perforation (GBP) with fistulous communication (Neimeier type I) is controversial.

To recommend management options for GBP with fistulous communication.

A systematic review of studies describing the management of Neimeier type I GBP was performed according to the PRISMA guidelines. The search strategy was conducted in Scopus, Web of Science, MEDLINE, and EMBASE (May 2022). Data extraction was obtained for patient characteristics, type of intervention, days of hospitalization (DoH), complications, and site of fistulous communication.

A total of 54 patients (61% female) from case reports, series, and cohorts were included. The most frequent fistulous communication occurred in the abdominal wall. Patients from case reports/series had a similar proportion of complications between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) (28.6 vs 12.5; P = 0.569). Mortality was higher in OC (14.3 vs 0.0; P = 0.467) but this proportion was given by only one patient. DoH were higher in OC (mean 26.3 d vs 6.6 d). There was no clear association between higher rates of complications of a given intervention in cohorts, and no mortality was observed.

Surgeons must evaluate the advantages and disadvantages of the therapeutic options. OC and LC are adequate options for the surgical management of GBP, with no significant differences.

• Gallbladder perforation
• Open cholecystectomy
• Laparoscopic cholecystectomy
• Fistulous communication

Neimeier, in 1934, proposed a classification for gallbladder perforation. The first type is fistulation between the gallbladder and adjacent viscerae. The second type is a subacute perforation surrounded by an abscess walled off by adhesions from the general peritoneal cavity; and the third type is a peritonitis due to free biliary spillage into the peritoneal cavity without protective adhesions. We will analyze a Neimeier’s type 1 perforation. The patient is a 72-year-old male diagnosed with a cholecystolithiasis and empyema due to a cholecystopleural fistula. Was operated by laparoscopic surgery because its low rate of complications, and lower days at hospital staying. Everything went as planned with no complications. Even though it is not a common presentation, it sets a precedent for it to be furthermore researched, and for it to be used as a literary option in a discussion to know which type of surgery is better for these cases.

• Universidad Autónoma de Nuevo León, Hospital Universitario ‘Dr. José Eleuterio González’

Bilothorax is a rare cause of an exudative pleural effusion. The diagnosis is confirmed by a pleural fluid to serum bilirubin ratio of greater than 1. Typically, bilothorax presents as a right-sided effusion due to its proximity to the liver and biliary system. Herein, we present a case of isolated left-sided bilothorax in a 43-year-old female admitted with sickle cell crisis. Only one other case of isolated spontaneous left-sided bilothorax has been described in the literature. A thoracentesis performed on admission demonstrated greenish fluid and bilothorax was suspected, with a pleural fluid to serum bilirubin ratio greater than 1 confirming the diagnosis. A magnetic resonance cholangiopancreatography (MRCP) showed an abnormal 90-degree acute angulation in the mid-to-distal common bile duct with proximal common bile duct and intrahepatic bile ducts dilation. This was further confirmed with an endoscopic retrograde cholangiopancreatography (ERCP), which did not reveal any extravasation of contrast into the left pleural space. Ultimately, despite the use of various modalities, no definitive cause of bilothorax was identified. Postthoracentesis imaging revealed evidence of fibrothorax, a direct and permanent complication of bilothorax. The presence of an isolated left-sided bilothorax, along with the lack of a confirmed etiology, makes this case unique.

A 13-year-old spayed female domestic shorthair cat presented with pleural effusion and suspected triaditis. Intake vitals and leukocytosis were consistent with a diagnosis of systemic inflammatory response syndrome. Biochemical analysis confirmed a pleural fluid-to-serum bile ratio consistent with a diagnosis of biliothorax. Abdominal ultrasound failed to identify a definitive gall bladder but noted a hypoechoic tubular structure ventral to the liver and contacting the diaphragm. Thoracic ultrasound identified a hyperechoic structure contacting the diaphragm at the same location. Thoracoabdominal CT scan identified a fluid-dense tubular structure extending from ventral to the liver, through a diaphragmatic defect and directly communicating with the pleural space, suspected to be an abnormal gall bladder. The cat was humanely euthanized, and post-mortem analysis confirmed a cholecystopleural fistula arising from the gall bladder with multifocal abscesses, mixed inflammatory hepatic infiltrates and small-cell gastrointestinal lymphoma. Culture of the abscess isolated Parabacteroides merdae, meeting the reported feline criteria for sepsis.

To our knowledge, spontaneous cholecystopleural fistula formation leading to biliothorax and sepsis has not been previously reported in the cat. This case highlights a novel sequela of gall bladder disease in this species, and biliothorax should be a differential diagnosis for pleural effusion in cats with evidence of cholecystitis or triaditis.

• Biliothorax
• SIRS
• cholecystopleural fistula
• sepsis
• systemic inflammatory response syndrome
• triaditis

• Bilious pleural effusion
• Glycoholic acid
• Pathophysiology
• Ratio of pleural total bilirubin to serum total bilirubin

A 28-year-old male presented with fever with right-sided chest pain for 2 weeks. Clinicoradiological picture was suggestive of right-sided pleural effusion. He had history of polytrauma following a road traffic accident and had to undergo emergency laparotomy a month ago. Microscopic and culture examination of the pleural fluid showed neutrophilia, high bilirubin content and presence of gram-negative bacilli. Ultrasound of the abdomen showed the presence of biloma in the liver and right subdiaphragmatic space with fistulous communication into the right thoracic cavity. The patient was managed successfully with complete recovery.

• Biliopleural fistula
• biloma
• pleural effusion

• Complications
• Fistula
• Gallstones
• Lost stones
• Obstruction

• bilothorax
• bilio-enteric bypass
• pleurobiliary fistula

• Bile
• Cholecystectomy/adverse effects
• Diagnosis, Differential
• Fatal Outcome
• Female
• Humans
• Middle Aged
• Myocardial Infarction/diagnosis
• Peritonitis/complications
• Pleural Effusion/diagnostic imaging
• Pleural Effusion/etiology
• Radiography
• Venous Thromboembolism/diagnosis

• Cholecystectomy, Laparoscopic
• Cholelithiasis/diagnostic imaging
• Foreign-Body Migration/diagnostic imaging
• Humans
• Male
• Middle Aged
• Pleura/diagnostic imaging
• Postcholecystectomy Syndrome/diagnostic imaging
• Tomography, X-Ray Computed

• Bronchial Fistula/diagnosis
• Bronchial Fistula/etiology
• Bronchial Fistula/surgery
• Cholecystectomy, Laparoscopic/adverse effects
• Chronic Disease
• Female
• Fistula/diagnosis
• Fistula/etiology
• Fistula/surgery
• Humans
• Klebsiella Infections/complications
• Klebsiella pneumoniae
• Middle Aged
• Peritoneal Diseases/diagnosis
• Peritoneal Diseases/etiology
• Peritoneal Diseases/surgery
• Subphrenic Abscess/complications

• Aged
• Cholecystectomy, Laparoscopic/adverse effects
• Cholelithiasis/complications
• Cholelithiasis/surgery
• Disease-Free Survival
• Empyema, Pleural/diagnostic imaging
• Empyema, Pleural/etiology
• Empyema, Pleural/surgery
• Female
• Humans
• Radiography
• Thoracotomy

• Acute Disease
• Aged
• Bile
• Biliary Fistula/complications
• Biliary Fistula/diagnosis
• Biliary Fistula/surgery
• Cholelithiasis/complications
• Cholelithiasis/diagnosis
• Cholelithiasis/surgery
• Diagnosis, Differential
• Gallbladder Diseases/complications
• Gallbladder Diseases/diagnosis
• Gallbladder Diseases/surgery
• Humans
• Male
• Pleural Diseases/complications
• Pleural Diseases/diagnosis
• Pleural Diseases/surgery
• Pleural Effusion/diagnosis
• Pleural Effusion/etiology
• Pleural Effusion/surgery
• Respiratory Insufficiency/diagnosis
• Thoracic Diseases/diagnosis
• Thoracic Diseases/etiology
• Thoracic Diseases/surgery

• Aged
• Bile
• Calculi/chemistry
• Calculi/diagnosis
• Calculi/etiology
• Cholecystectomy, Laparoscopic/adverse effects
• Humans
• Male
• Pleura/pathology
• Pleural Diseases/diagnosis
• Pleural Diseases/etiology
• Pleural Effusion/diagnosis
• Pleural Effusion/etiology
• Thoracoscopy