Introduction: The Liver is a highly vascular organ that is vulnerable to traumatic injury because of its size and fixed position in the right hypochondrium. We present a unique case of a patient who presented with hepatic rupture following vigorous coughing. Case description: An 83 year-old female with history of chronic obstructive pulmonary disease presented with epigastric pain, nausea and vomiting following an episode of vigorous cough on exposure to dust. She denied hematemesis, melena or fever. Physical examination: heart rate 102/min, and blood pressure 109/56 mm Hg, decreased breath sounds with bilateral wheezing, diffusely tender, distended abdomen with guarding but no rigidity. Laboratory data: Total bilirubin 4.5 mg/l, Aspartate transaminase 43 IU/l, Alanine transaminase 99 IU/l, Alkaline phosphatase 136 IU/l, Serum lipase 51 U/l, negative hepatitis panel. Chest X-ray showed no rib fractures. Computed tomography (CT) revealed large fluid collection posterior to the stomach, no bowel perforation or cholecystitis. CT guided drainage showed bilious fluid. She was initially managed conservatively with the drain in place but failed to improve. Endoscopic retrograde cholangiopancreatography (ERCP) showed an obvious leak of contrast from the left lobe of the liver flowing and draining through the drain. Sphincterotomy and stent placement were done during ERCP with significant improvement in her condition. Hepatobiliary (HIDA) scan after 4 weeks showed no bile leak and stent was removed. Discussion: Hepatic laceration is often a fatal complication of trauma, pregnancy, anticoagulant therapy, connective tissue disorders, liver infiltrative diseases, hepatocellular carcinomas, and rarely cough as in our case. Patients present with severe right upper quadrant pain, abdominal distention, anemia or hypotension. Suspicion of injury is raised from presentation, physical examination and laboratory findings. CT abdomen usually confirms the injury and defines injury grade. Biliary tree disruption is a frequent complication of non-operative management; diagnosis and evaluation of the leak site may be made by ERCP and HIDA scan. Drainage of the bile collection followed by close observation serves as definitive therapy, but some patients have persistent bilious drainage that can be managed by ERCP with sphincterotomy and/or biliary stent placement. Conclusion: Hepatic laceration, though life-threatening, is not a well-described complication of cough. This report provides a detailed account of such a complication along with an unlikely site of bile collection occurring secondary to vigorous coughing.Figure 1Figure 2Figure 3