A man with shortness of breath and chest pain.

Abstract

A 40-year-old man with a history of a prior exploratory laparotomy and pericardial window for trauma presented to the emergency department several hours after the sudden onset of shortness of breath, chest pain, and vomiting. Heart rate was 169 beats/min. Respiratory rate was 38 breaths/min. Other vital signs were normal. Abdominal examination revealed distension without tenderness. Physical examination was otherwise unremarkable. Chest radiography showed a lucency surrounding the mediastinum (Figure 1). Computed tomography (CT) of the chest, abdomen, and pelvis was performed (Figure 2). Intrapericardial diaphragmatic hernia (IPDH). CT showed a large intraabdominal fatty tumor causing herniation of the colon through the prior pericardial window as well as pneumopericardium with air-fluid levels, which suggested intestinal perforation. The patient received intravenous fluids and broad-spectrum antibiotics and was taken to the operating room for exploratory laparotomy, tumor excision, pericardial drainage, and colectomy. Surgical pathology from the tumor revealed liposarcoma. A pericardial window is a surgical procedure for drainage of pericardial fluid and can be performed using a subxiphoid or transthoracic approach.1, 2 IPDH years after a subxiphoid pericardial window is rare but can occur, most commonly after blunt abdominal trauma.3-5 Patients can present with signs of bowel obstruction or cardiac dysfunction, including tamponade. Chest radiography can be helpful, but CT is often necessary for diagnosis. Management involves prompt surgical consultation for repair and possible bowel resection if there is concern for strangulation. Prognosis is good if recognized quickly, though long-term studies assessing outcomes have not been published.