Spontaneous Biliary Pericardial Tamponade: A Case Report and Literature Review

Abstract

Background: Biliary pericardial tamponade (BPT) is a rare form of pericardial tamponade, characterized by yellowish-greenish pericardial fluid upon pericardiocentesis. Historically, BPT reported to occur in the setting of an associated pericardiobiliary fistula. However, BPT in the absence of a detectable fistula is extremely rare.

Learning objective: A biliary pericardial tamponade is a rare form of tamponade warranting a prompt workup (e.g., MRCP or HIDA scan) for a potential fistula between the biliary system and the pericardial space. A pericardio-biliary fistula can be iatrogenic or traumatic. People with a history of chest wall trauma, abdominal surgery, or chest surgery are at increased risk. The use of HIDA scanning plays a salient role in effectively surveilling for the presence of a fistula - especially when MRCP is contraindicated.

Case presentation: A 75-year-old Hispanic male presenting with dyspnea and diagnosed with cardiac tamponade is the subject of the study. Subsequent pericardiocentesis revealed biliary pericardial fluid (bilirubin of 7.6 mg/dl). The patient underwent extensive workup to identify a potential fistula between the hepatobiliary system and the pericardial space, which was non-revealing. The mechanism of bile entry into the pericardial space remains to be unidentified.

Literature review: A total of six previously published BPT were identified: all were males, with a mean age of 53.3 years (range: 31-73). Mortality was reported in two out of the six cases. The underlying etiology for pericardial tamponade varied across the cases: incidental pericardio-biliary fistula, traumatic pericardial injury, and presence of associated malignancy. - Conclusion: Biliary pericardial tamponade is a rare form of tamponade that warrants a prompt workup (e.g., Hepatobiliary Iminodiacetic Acid - HIDA scan) for an iatrogenic vs. traumatic pericardio- biliary fistula. As a first case in the literature, our case exhibits a biliary tamponade in the absence of an identifiable fistula.

Keywords: BPT; Pericardial effusion; biliary cardiac effusion; cardiac tamponade; pericardiobiliary fistula; pericardiocentesis..

Fig. (1)

(a) CT scan of the chest (prior to pericardiocentesis) showing moderate to large pericardial effusion (arrowed). (b) Contrast-enhanced chest CT scan (day 1 following pericardiocentesis) revealed persistent pericardial effusion (arrowed) as well as pericardial enhancement suggestive for the inflammatory or infectious process; no malignant lesion identified. (c) Calcified subcarinal lymph node (single arrow) and hypodense lesion in the liver (doubled arrows) could also be identified. (d) Repeat chest CT scan at one-month post-pericardiocentesis showing minimal reaccumulatiung pericardial fluids and trace pleural effusions. The pericardial air has resolved. (A higher resolution / colour version of this figure is available in the electronic copy of the article).

Fig. (2)

(a) Transthoracic Echocardiography (TTE) showing the apical 4-chamber view with large circumferential pericardial effusion (yellow arrow) and echodense layer on along the visceral surface of the pericardium representing pericardial fat, soft tissue or fibrin deposits. (b) Subcostal view showing the inferior vena cava (double arrows) to be dilated with less than 50% inspiratory collapse at the level of hepatic veins (single arrow points to the liver). (A higher resolution / colour version of this figure is available in the electronic copy of the article).

Fig. (3)

(a) Dedicated abdominal CT scan showing a small (1.3 cm in diameter) low-density lesion in the liver (arrowed) of uncertain etiology. (b) Right upper quadrant ultrasound showing a hypodense echogenic liver lesion measuring 1.8 cm (arrowed). (A higher resolution / colour version of this figure is available in the electronic copy of the article).

Fig. (4)

Hepatobiliary Iminodiacetic Acid (HIDA) scan performed with an infusion of technetium 99m labeled Choletec showing a rapid clearance of blood pool activity indicating normal hepatic function. At 1 hour, the liver is essentially cleared. While bile duct and small bowel activities are present, there is no evidence of activity within the pericardium. There is no activity seen within the gallbladder, which is surgically absent (i.e., cholecystectomy). There is no evidence of a biliary system to the pericardial fistula. (A higher resolution / colour version of this figure is available in the electronic copy of the article).