E3256. Gas, Gas Everywhere! Stranger Things About Fistulas in the Chest and Abdomen
  1. Praveen Polamraju; Atrium Health Wake Forest Baptist Health
  2. Tyler Brenneman; Atrium Health Wake Forest Baptist Health
  3. Adam Petraglia; Atrium Health Wake Forest Baptist Health
  4. Wencheng Li; Atrium Health Wake Forest Baptist Health
  5. Lindsay Duy; Atrium Health Wake Forest Baptist Health
  6. Janardhana Ponnatapura; Atrium Health Wake Forest Baptist Health
Many fistulas in the chest and abdomen are uncommon and can be often subtle or difficult to identify on imaging. Often, the only clues may include fluid or gas collection in an abnormal place. However, a thorough knowledge about the best imaging modalities with specific protocols may help the radiologist to confirm the findings and allow for early surgical intervention to prevent serious morbidity and mortality. We would like to comprehensively present strange fistulas in the chest and abdomen.

Educational Goals / Teaching Points
The first objective is to understand the definition of a fistula. The second is to understand risk factors and etiologies of a fistula. The third objective is to recognize suspicious findings for uncommon fistulas on imaging. The fourth is to understand the use of specific contrast protocols and modalities to confirm suspicious findings for uncommon fistulas. The fifth is to identify complications of fistulas on imaging. The sixth is to understand the management of a fistula and its complications, correlating imaging findings with operative or procedural findings.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Risk factors for fistulas include the postsurgical/post-procedural state, neoplasms, infection, or inflammatory conditions. Corresponding clues on imaging include identifying a gas or fluid collection, loss of fat plane, or an identifiable tract. The risk factors in combination with clues raise suspicion for a fistula. For example, a 71-year-old with history of prior Roux-en-Y and NSAID use presented with chest pain and dyspnea. CXR and CT demonstrated pneumopericardium, with CT demonstrating an adjacent gas and fluid collection in the abdomen. A CT with enteric contrast was then obtained due to high level of suspicion for gastropericardial fistula, which was confirmed on this study and at surgery. In a 73-year-old female with history of cholangiocarcinoma after radioembolization with bilioptysis and CT demonstrated an ill-defined collection in the hepatic dome. Clinical symptoms raised concern for bronchobiliary fistula, with HIDA demonstrating uptake in the right hepatic dome and surrounding the right lower lobe bronchus. Fluoroscopy confirmed the fistula, which was then embolized.

While uncommon fistulas in the chest and abdomen can be difficult to recognize, a high level of suspicion with clinical risk factors, appropriate imaging modalities and protocols, and imaging clues can help the radiologist successfully identify them to allow for early surgical intervention.