Posttraumatic pericardiobiliary fistula causing acute bilious pericardial tamponade.

CASE REPORT The patient is a 34-year-old man referred to Henry Ford Hospital for evaluation and treatment of a posttraumatic bile leak associated with pericarditis and a pericardial effusion. Approximately 5 weeks before transfer, the patient was shot in the abdomen. Operative intervention included a left hepatic lobectomy with 20 units of packed red blood cells transfused. He returned to the operating room the next day for a second look laparotomy without an evidence of a bile leak. Leukocytosis and hyperbilirubinemia developed on postoperative day (POD) 5. Both levels continued to increase. On POD 11, endoscopic retrograde cholangiopancreatography (ERCP) was performed. ERCP demonstrated proximal common bile duct obstruction was believed to be secondary to hematoma. Biliary stenting and sphincterotomy resulted in normalization of the serum white blood cell and bilirubin levels. Dyspnea and leukocytosis resulted the following day. Computed tomography (CT) scanning of the chest revealed an infected biloma. CT-guided percutaneous drainage of the bile abscess was performed the next day with 80 mL of bile aspirated, and a pigtail catheter was placed. The aspirated fluid was icteric, and chemical analysis reported an increased lactate dehydrogenase (LDH) level of 5,588 IU/L. Cultures were negative. Gram staining showed no organisms. The fluid white blood cell count was 1,611/mL with 85% neutrophils. Antibiotics were held. Hydroxy iminodiacetic acid (HIDA) scan disclosed nothing abnormal for a biliary leak. The Jackson-Pratt drain placed at the second-look laparotomy continued producing 200 mL to 300 mL of bile daily. The patient’s clinical condition improved and he was discharged to home. Repeat outpatient CT scanning on POD 19 demonstrated an interval increase in the size of the infected biloma. CT-guided drainage of the abscess produced 250 mL of bile, and a pigtail catheter was placed. Twenty-four hours later, he was readmitted with complaints of fever, chills, and chest pain. Serum white blood cell count was 18,400 cells/ L. Electrocardiogram demonstrated pericarditis. Distant heart sounds noted on physical examination contradicted a two-dimensional echocardiogram demonstrating no evidence of pericardial effusion. Fluid culture was positive for Enterobacter aerogenes and Candida albicans. Broad-spectrum antibiotics were begun. Daily octreotide was also prescribed. Repeat CT scan on POD 36 demonstrated interval development of a large pericardial effusion, increased bilateral pleural effusions, and prominent mediastinal lymphadenopathy. Electrocardiogram changes were consistent with worsening pericarditis. HIDA scan was positive for a biliary leak. The patient was transferred to the Henry Ford Hospital for transplantation or hepatobiliary operation service on POD 39. Repeat CT imaging (POD 40) demonstrated a moderate pericardial effusion with an associated left upper quadrant phlegmon. Antibiotic coverage was initiated. The JacksonPratt drain placed at the previous institution seemed to abut or lie within the pericardium. Drain cultures were positive for Acinetobacter baumannii. Two-dimensional echocardiography (POD 41) revealed a small pericardial effusion with a large posterior pleural effusion and no evidence of a foreign body within the pericardium. The patient continued to complain of chest pain and remained febrile, dyspneic, and leukocytotic. Repeat CT scanning (POD 45) demonstrated a large pericardial effusion causing mass effect on the right ventricle (Fig. 1) and possible communication to an enlarging left upper quadrant complex fluid collection. Two-dimensional echocardiography confirmed a large fibrinstranded pericardial effusion with severe right ventricular chamber collapse, thickened pericardium, and a moderatesized left pleural effusion. On the basis of the CT and echocardiogram findings, the patient was taken to the operating room for an emergent pericardiectomy. Scarring prevented visualization of the pericardium through an initial subxiphoid approach. The subxiphoid incision was then extended and a full median sternotomy was performed. Scissors incised the pericardium that was markedly thickened to 2 cm. Four hundred milliliters of bile was evacuated from the pericardial space. Hemodynamics improved immediately. Bovie electrocautery was used to excise the pericardium from the left phrenic nerve to the right phrenic nerve and from the diaphragm to the base of the Submitted for publication May 19, 2007. Accepted for publication October 23, 2007. Copyright © 2010 by Lippincott Williams & Wilkins From the Department of Cardiothoracic Surgery, Henry Ford Hospital, Detroit, Michigan. Address for reprints: Wesley B. von Riedenauer, MD, Department of Cardiothoracic Surgery, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202; email: vonriedenauer@yahoo.com.