Acute Pneumopericardium Due to Intestino-Pericardial Fistula
A 70-year-old woman with a 5-month history of metastatic pancreatic cancer was admitted to the hospital with dyspnea, swelling edema of the legs, and fever. Shortly thereafter she developed an intermittent atrial fibrillation. Treatment with diuretics, antibiotics, and amiodarone was initiated. Because of a chest radiograph showing a pneumopericardium, she was transferred to our University Medical Center (Figure 1). Transthoracic echocardiography was hampered by pericardial trapped air. A 64-row multislice computed tomography scan that was initially performed for re-staging of the pancreatic carcinoma after systemic chemotherapy (gemcitabine) and intraarterial chemoperfusion (gemcitabine and mitomycin) of a solitary liver metastasis revealed no detectable residual tumor masses. However, orally administered contrast agent was visible in the pericardial sac (Figure 2) and an exceptionally close spatial relation of the pericardial sac to the esophagus and cardia was observed. There was no mediastinal or intra-abdominal contrast extravasate or air indicative of either an esophageal rupture or a gastrointestinal perforation. Therefore, an intestino-pericardial fistula at the height of the diaphragm was suggested and consecutively verified using an esophagogram with a water-soluble contrast agent (Figure 3 and Movie). Subsequent laparotomy uncovered a large ulceration at the gastroesophageal junction, adhering to the pericardium. After mobilization of the ulcer, massive purulent pericardial effusion was protruding (Figure 4). Histology of the ulcer revealed a florid, chronically granulated, and scarred inflammation. Hypothetically, the damage to the mucosa might have been related to the arterial chemoperfusion, eventually including the gastric arterial supply due to proximal administration in the celiac trunk. The operative procedure consisted of a thorough lavage of the pericardium, resection and sutured patch of the ulcer, fundoplication, and placement of a pericardial drainage. Because of microbiological evidence of enterococcus faecium and candida albicans, antibiotic treatment was escalated and adapted. The patient recovered gradually, and her general condition is now markedly improved.
The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/114/1/e7/DC1.