Penetrating thoracoabdominal trauma, with potential injury to two anatomic cavities, poses a significant diagnostic and therapeutic challenge. This is especially true with reference to detection of diaphragmatic injuries, where development of a bilio-pleural fistula is a rare phenomenon. The optimal management in such cases has not been clearly defined as both conservative and emergency surgical approaches have been tried in acute settings. We report a patient who suffered an accidental penetrating wound to the right thoracoabdominal region. The patient developed a bilio-pleural fistula immediately following the injury with imaging showing an intact diaphragm. The case was managed conservatively using endoscopy as the primary modality for treating the primary condition as well as a rare complication of biliary stent migration. Thus an endoscopic approach is feasible in management of bilio-pleural fistula when used in properly selected cases.
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