Gastric Tube–Pericardial Fistula
A Late Complication of Esophageal Reconstruction
A 54-year-old man presented to the emergency department with an insidious onset of chest tightness and exertional dyspnea for 1 week. He had received a diagnosis of esophageal carcinoma and undergone surgery with retrosternal esophageal reconstruction by use of a gastric tube in 2006. At the emergency department, his blood pressure was 138/88 mm Hg, and his pulse rate was 80 bpm. Blood tests showed a white blood cell count of 16 100/mm3 and elevated C-reactive protein of 27.07 mg/dL. A chest radiograph and thoracic computed tomography revealed massive pericardial effusion and pneumopericardium (Figure 1A,B). A transthoracic echocardiogram disclosed pericardial effusion with much hyperechoic material, comet-tail artifacts, and mild compression of the right atrium (Figure 1C). However, the pulse wave Doppler study of mitral inflow showed fused E and A waves without significantly respiratory variations (Figure 1D). Diagnostic pericardiocentesis was performed, and approximately 500 mL milky fluid accompanied by undigested vegetables was drained (Figure 2A). The reconstructed gastric tube–pericardial fistula was visualized by the giving of 30 mL of 0.1% methylene blue and the following blue-stained drainage of pericardial effusion (Figure 2B). Analysis of the pericardial fluid revealed marked elevated amylase level (>12 000 U/L). Urgent surgery disclosed a 2×2-cm perforated ulcer of the gastric tube communicating with the pericardium (Figure 2C). The fistula was repaired, and symptoms were relieved. Culture of the pericardial fluid revealed microbial growth of Enterobacter aerogenes, Serratia odorifera, and Candida albicans, compatible with mixed oral and gastrointestinal tract flora. Broad-spectrum antibiotics and an antifungal agent were prescribed. Unfortunately, the sutured fistula ruptured 2 weeks later, and the patient experienced profound sepsis and died.
Although esophagopericardial fistula is not usual, it is one of the differential diagnoses of chest pain in patients with esophageal or gastric tumors. The prognosis is usually poor, in that more than 70% of patients die within 1 month, not only because of underlying malignancies but also because of the accompanying purulent pericarditis.1 The diagnosis of esophagopericardial fistula remains challenging because of a low suspicion in most patients, and urgent surgical intervention after a quick diagnostic test is warranted to obtain a better outcome.1 The most common chest x-ray finding is pneumopericardium. Computed tomography with oral contrast medium has been suggested to be the initial diagnostic imaging modality; however, failure to demonstrate a fistulous communication should not be interpreted as absence of the disease. In 20% of these patients, pericardial effusion would not be demonstrated by contrast enhancement.2 In the case reported here, chest computed tomography did not indicate the presence of a pericardial fistula. However, pericardiocentesis followed by a methylene blue test was a simple and useful method to confirm the presence of an esophagopericardial fistula, perhaps because methylene blue is more water soluble than contrast medium, and it is more practical as a bedside test in patients who have undergone pericardiocentesis for diagnosis or cardiac tamponade.
Here we report a rare case of a gastric tube–pericardial fistula developing 3 years after esophageal reconstruction. Although the patient underwent urgent surgery after a simple methylene blue test, he died as a result of rupture of the repaired gastric tube. Patients who have undergone esophageal replacement require lifelong follow-up. Physicians observing these individuals should have a low threshold for screening and an aggressive attitude to treat patients for peptic ulcer disease.