incidental Demonstration f Pericardial Fistula During Hepatobiliary Scintigraphy

Biliary vomiting developed 16 mo after resection of ade-nocarcinoma of the esophagus in a patient with a complex postoperative course. A biliary scan revealed an outline of the pericardium, suggesting a fistula. The potential role of radionuclide imaging in this rare and potentially fatal com-plication is discussed. J Nucl Med 1991; 32:518-520 F is tu lous connection to the pericardium is a rare and frequently fatal complication of benign and malig-nant processes involving adjacent structures. Esopha-gopericardial fistulas are the most common (1), but pericardial fistulas from the stomach (2), duodenum (3), colon (4,5), liver (6), je junum (7), pleura, and cutaneous tissues (8) have been reported. We present an incidental finding of a pericardial fistula during routine hepatobiliary imaging. CASE REPORT A 48-yroold male was admitted for nausea, bilious vomiting, and abdominal pain. He had been diagnosed with adenocar-cinoma of the distal esophagus 16 mo prior to this admission and had undergone resection. Postoperatively, he continued to have intermittent anorexia nd dysphagia, requiring dila-tation of strictures and, eventually, placement of an endo-prosthesic stent in the distal esophagus 6 wk prior to this presentation. Physical exam on admission was remarkable for ascites which paracentesis proved to be malignant. Computed to-mography scan showed changes consistent with the previous surgeD ' but there was additional soft-tissue density surround-ing the distal stent suggestive of tumor recurrence. The liver, gallbladder, and pancreas were noted to be normal. A supine film of the abdomen demonstrated a gasless abdomen. A limited upper gastrointestinal series was performed to look for obstruction. The stent was patent, the stomach taut and poorly distensible, bul barium did eventually enter the duodenum