Greenish sputum (Bilioptysis) An enigma in Gastroenterology

Broncho-biliary fistula (BBF) is a communication between the biliary system and the bronchial tree. It manifests as bilioptysis (coughing of bile). It is quite rare but a serious complication. There are many hepatobiliary conditions leading to the development of BBF. The most common is drainage of intra-hepatic abscess subsequently leading to fistula formation between the biliary tree and pulmonary tree. It most commonly presents with chronic cough and production of greenish sputum. It can rarely present as acute pneumonitis. The mechanism of fistula formation is not clear, but is believed that local inflammatory process lead to false communication between the biliary tree and bronchi. There are various modalities to demonstrate BBF, but the most definitive methods are PTC, HIDA and ERCP. Here we report 2 cases of BBF, one due to hepatic abscess and the other due to PTBD for CBD obstruction secondary to inoperable hilar cholangiocarcinoma. BBF was demonstrated by HIDA in the first patient and the other patient by ERCP. Both patients were treated with ERCP and biliary stenting. They had gradual resolution of bilioptysis.