Radiological Case

Pericardiobiliary Fistula: A Rare Complication of Penetrating Abdominal Trauma

Craig Chavez, MD; David Golchian, DO; Donald Conn, MD; John Finger, MD

Disclosures

Appl Radiol. 2018;47(8):24-26. 

In This Article

Discussion

Pericardiobiliary fistula is a rare but serious complication of penetrating trauma to the thorax and only one case has been reported. In the review of the literature, a single case of iatrogenic percardiobiliary fistula formation after emergent sub xiphoid approach pericardial drain placement was found. Thoracobiliary fistula has been reported as a complication of infective or obstructive biliary process. It is considered exceedingly rare following penetrating injury. Disruption of both biliary and diaphragmatic tissues is required for the fistula formation.[1] In our case, the penetrating abdominal trauma resulted in extensive hepatic damage with disruption of the diaphragm and associated pericardial injury.

The biliary pressure relationship has been described in the literature and it is believed that inflammation and possibly infection from preceding trauma may play a role in fistula formation. In our case, the antecedent trauma is most likely the cause of the pericardiobiliary fistula. In comparison to the previously described case of post traumatic pericardiobiliary fistula,[2] the patient did not undergo surgical intervention for the initial injury prior to fistula formation excluding a possible iatrogenic cause.

Cardiac tamponade was present on both reported cases of post traumatic and iatrogenic pericadiobiliary fistula. In our case, the patient was symptomatic from his effusions but not in cardiac tamponade. It is unclear what the determining factor is for the development of tamponade, some degree of biliary obstruction may be a contributing factor.[3]

Management of pericardiobiliary fistula usually requires surgical intervention.[2] Endoscopic retrograde cholangiography is very useful as the initial procedure to confirm the diagnosis and also for treatment planning as it can accurately delineate the extent of the damage to the biliary system. It also has the potential for being therapeutic. Our patient also underwent ERCP, the left intrahepatic bile duct was found to be severed with free leakage of contrast above the bifurcation suggesting biliary leak (Figure 4). Subsequently the patient underwent exploratory laparotomy with left hepatectomy and closure of the diaphragmatic injury.

In non-surgical patients pericardiobiliary fistulas can be managed with image guided percutaneous biliary decompression and pericardiocentesis.[3] There is little consensus on the optimal medical management which can lead to delayed diagnosis and treatment. In cases of thoracobilliary fistula, conservative approaches and placement of a biliary stent has been favored.[4] It is believed that placement of stent facilitates bile drainage into the duodenum by reducing the pressure and negating sphincter of Oddi resistance and reduces the bile duct pressure which possibly promotes healing of the fistula. Although most small biliary fistulae resolve after drainage of the bile collection, the failure rate of conservative treatment of large fistulae is reported to be as high as 38%.[5] Persistence of fistulae is due to the negative pressure within the pericardial space and relatively elevated pressure within the biliary system from sphincter of Oddi. The utility of magnetic resonance cholangiography has yet to be established.[6]

Postoperative imaging in our patient demonstrated resolution of the pericardial effusion. The pericardial drain was later removed. The patient's recovery was complicated by aspiration cardiac arrest with re-intubation and abdominal abscess formation requiring percutaneous drainage and antibiotics.

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