A case of pneumopericardium

Abstract

A 77-year-old female with history of abdominal aortic aneurysm, COPD and Nissen fundoplication surgery for a hiatal hernia 10 years ago, was admitted with a one day history of sudden onset sharp retro-sternal chest pain radiating tothe back. She was hemodynamically stable. Chest X-ray and CT scan of the chest showed evidence of a significant pneumomediastinum and pneumopericardium with the greatest anterior depth of 3.8 cm. No pulmonary blebs were present on CT. Physical exam positive for Hamman’s crunch and pulsus paradoxus of 15 mmHg. Esophagram, bronchoscopy and EGD failed to show any evidence of fistulas. Trans-thoracic echocardiogram showed no evidence of cardiac tamponade. CT guided pericardial drainage was negative for gas-forming pathogens. She underwent thoracic exploratory surgery and intraoperative insufflation of the stomach revealing a gastro-pericardial fistula at the fundoplication wrap that was repaired. Pathology report showed thickened and inflamed pericardium. Patient’s pneumopericardium resolved and follow up imaging at six months showed no recurrence. The patient’s history of Nissen fundoplication predisposed her to gastric ulceration, which complicates almost 5% of cases with subsequent gastropericardial fistula formation. The most common risk factor for a gastropericardial fistula is history of gastro-esophageal surgery. While this is a rare finding to see in practice, one should be aware of the possibility of gastropericardial fistula in patients with previous history of gastric surgery who present with spontaneous pneumopericardium.