157: SPONTANEOUS PNEUMOPERICARDIUM IN THE SETTING OF GASTROPERICARDIAL FISTULA: A CASE REPORT

Abstract

Introduction: Though a rare cause, gastro-pericardial fistula should be considered and ruled out in the setting of non-traumatic pneumopericardium. Prior bariatric or gastrointestinal surgery should elicit the provider’s suspicion for further workup. Complications include cardiac arrhythmias, sepsis, cardiac arrest, and death. Treatment is primarily surgical with pericardial window and surgical correction of the fistula. Description: A 56-year-old male with a history of gastric bypass presents to the emergency room with dyspnea and left-sided chest pain and becomes hemodynamically unstable with tachyarrhythmia. Imaging is consistent with a pneumopericardium. The patient is taken to the operating room where Esophagogastroduodenoscopy (EGD) shows gastropericardial fistula. He undergoes surgical correction and is returned to Cardiac Care Unit (CCU) where he suffers cardiac arrest. Discussion: Pneumopericardium is a collection of gas within the pericardial cavity and is usually found as a consequence of trauma (blunt and penetrating) in about 60% of patients. In the absence of trauma, other causes of pneumopericardium should be evaluated. Fistulization (from the airways, mediastinum, gastrointestinal tract, and peritoneum), infection (abscesses, pericarditis), complications of surgery or invasive procedures, and congenital abnormalities should be considered. Gastropericardial fistula is a rare and often life-threatening condition. A review in 2016 by Azzu, V reported under 65 described cases in the literature. Chest and shoulder pain was the most common physical finding followed by dyspnea (66 and 20% respectively) with a mean age of 59 years at presentation. Diagnosis includes imaging with air in the pericardial space and echocardiography for rapid assessment of effusion and tamponade physiology. Consensus for the use of upper endoscopy is mixed but should provide visualization of the fistula. Treatment involves pericardial window, gastrointestinal tract repair, and fistula closure. Systemic antibiotic use is essential for the management of infection and septic shock. Hemodynamic and respiratory support should be implemented as necessary with nutritional support and electrolyte balance optimization.