Katia Kaplan-List. M.D, M.A.

A PATIENT WITH CHEST PAIN

INITIAL CHEST RADIOGRAPH

CAUSES OF PNEUMOPERICARDIUM

• Penetrating trauma, e.g. stab wound

• Blunt trauma, e.g. high speed MVC

• Barotrauma, usually infants on high ventilator pressure

• Pericarditis due to gas forming organisms

• Intrapericardial perforation of lung abscess or tuberculosis cavity

• Perforated benign or malignant ulcers with bronchopericardial,

esophagopericardial, and gastropericardial fistulae

• Pneumopericardium has been reported to occur from sub-

diaphragmatic lesions namely anaerobic and pyogenic liver

abscesses that have penetrated through the diaphragm

• Foreign body aspiration

• Vigorous Valsalva, e.g. during sports, drug use

• Acute asthma

•

IATROGENIC CAUSES OF PNEUMOPERICARDIUM

• Sternal bone marrow puncture

• Thoracic surgery

• Thoracocentesis and pericardiocentesis

• Dental extraction

• Endoscopic procedures

• Laparoscopy

INITIAL CHEST CT

INITIAL CHEST CT

INITIAL CHEST CT

INITIAL ABDOMINAL CT

INITIAL ABDOMINAL AND CHEST CT

INITIAL ABDOMINAL CT

UPPER GI SERIES

CHEST RADIOGRAPH DAY 2

CHEST RADIOGRAPH DAY 5

CHEST RADIOGRAPH DAY 8

CT ABDOMEN DAY 11

Pericardial drain

Pericardial effusion

CT ABDOMEN DAY 11

Pericardial drain

Oral contrast

Abdominal drain

ESOPHAGRAM DAY 11

CHEST RADIOGRAPH DAY 13

CHEST RADIOGRAPH DAY 21

GASTROPERICARDIAL FISTULA

Gastropericardial fistula is a rare sequel of transdiaphragmatic perforation of a

gastric ulcer or carcinoma.

The stomach is usually intra-thoracic:

• hiatus hernia

• diaphragmatic hernia

• after oesophagectomy with gastric pull-up

Trans-diaphragmatic perforation of a gastric carcinoma or ulcer into the pericardium,

particularly in Zollinger-Ellison Syndrome, may also occur with an intra-abdominal

stomach.

CONCLUSION

Gastropericardial fistula is a rare condition with high mortality

Requires a high index of suspicion, early diagnosis and prompt surgical intervention

for a favorable outcome

Surgery is the definite treatment as patients rarely survive with conservative

management

Definitive management includes resection of the fistula, repair of the diaphragmatic

defect and dealing with the primary pathology of stomach

REFERENCES

1. Mirvis SE, Indeck M, Schorr RM et-al. Posttraumatic tension pneumopericardium: the

"small heart" sign. Radiology. 1986;158 (3): 663-9.

2. Karoui M, Bucur PO. Images in clinical medicine. Pneumopericardium. N. Engl. J.

Med. 2008;359 (14): e16.

3. Capizzi PJ, Martin M, Bannon MP. Tension pneumopericardium following blunt injury.

J Trauma. 1995;39 (4): 775-80.

4. Spontaneous Pneumopericardium Due to Exertion Gerald W. Westermann, MD,

Barbara Suwelack, MD South Med J. 2003;96(1)

5. S Sahu, S Agarwal, P Sachan, D Bahl. Gastropericardial Fistula: A Surgical

Emergency. The Internet Journal of Surgery. 2006 Volume 13 Number 2.

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