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.