A 67 year old woman with history of cholangiocarcinoma presents with worsening abdominal pain and postprandial productive cough with yellow-green sputum.
Prior treatment includes partial right hepatectomy, chemotherapy, chemoembolization, and stereotactic radiation. She is currently treated with bevacizumab. She presents for HIDA imaging.
There is an abnormal contour of the liver compatible with the prior right hepatic resection, and movement of radiotracer to the small bowel across a hepaticojejunal anastamosis.
There is also intermittent movement of radiotracer activity superiorly into the chest. This was further evaluated with SPECT/CT:
SPECT/CT images confirm radiotracer activity in the trachea, bronchus intermedius, and right lower lobe bronchi. Additional activity is seen in the upper esophagus.
Findings are compatible with bronchobiliary fistula.
In the uncommon case of suspected biliary fistula, HIDA imaging may extremely helpful in demonstrating the fistulous connection, which is not always apparent on anatomic imaging.
Bevacizumab (Avastin) is a monoclonal antibody used in treating certain malignancies, which works by inhibiting VEGF-A and tumor angiogenesis. Ischemia/Perforation and resulting fistulization have been described as infrequent but significant complications of patients with colorectal cancer treated with surgery and Avastin, and in patients with lung cancer treated with Avastin. The risk may be increased in the setting of radiation therapy. August DA, et al. J Surg Oncol 2008;97:180-5. Spigel DR, et al. J Clin Oncol 2010;28:43-8. Biliary fistulas have been described in patients with hepatic resection. Yoshioka Y, et al. Surg Today 2014;44:1300-6. Hevert K et al. ISMICS 2016 Annual Meeting.
