WHEN THE WAY TO A MAN'S HEART IS THROUGH THE STOMACH: A RARE CASE OF GASTRO-PERICARDIAL FISTULA AFTER PERCUTANEOUS GASTRIC TUBE DISPLACEMENT

Abstract

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gastro-pericardial fistula is an acquired abnormal communication between the stomach and the pericardium. We report one such case presenting as an unusual complication of percutaneous gastric tube (PEG) dislodgement. Early identification of this rare life-threatening condition can prevent fatal outcomes. CASE PRESENTATION: A 53-year-old male presented to our facility with acute substernal chest pain associated with dyspnea. He has a past medical history of chronic sclerosing peritonitis with a draining PEG tube. On presentation, his vital signs and physical examination were within normal limits. Laboratory investigation were unremarkable. Electrocardiogram (EKG) showed diffuse ST segment elevation concerning for pericarditis and he was started on steroids. During the course of his hospitalization his dyspnea worsened, and he subsequently underwent a Computerized Tomography(CT) scan of the chest which was significant for a pneumopericardium. An echocardiogram was performed which revealed a pericardial effusion which was free flowing without any stranding or loculations. There were no signs of tamponade. He consequently underwent an upper endoscopy which showed dislodgement of the PEG with the tip abutting the inferioapical region of the pericardium forming a fistulous tract. The PEG tube was therefore removed, and he was empirically treated with broad spectrum antibiotics. Endoscopic repair of the fistula was attempted, however it failed. Considering the clinical stability of the patient and absence of purulent drainage, the fistula was allowed to heal naturally while the patient remained on total parenteral nutrition in the Intensive Care Unit (ICU). DISCUSSION: Fistulous complications following PEG tube placement are extremely rare with an incidence of 0.3 to 6.7%. They have high mortality rate of 50%. Pneumopericardium can have a range of clinical presentations from being asymptomatic to presenting with chest pain, dyspnea, dyspepsia, epigastric pain, left shoulder due to diaphragmatic/pericardial irritation as well as sudden cardiac death due to cardiac tamponade. The diagnosis is challenging and is made using a combination of clinical suspicion, radiographic findings using small amount of methylene blue/contrast to visualize the fistula. An endoscopy may be helpful in establishing the diagnosis, but should be used with caution, because excessive air insufflation by the endoscope may exacerbate thecardiac tamponade. Treatment varies depending on the clinical stability and includes surgical closure of the fistula, pericardial drain placement or even conservative management. CONCLUSIONS: Gastro-pericardial fistula can be seen as a late complication of PEG tube and can present as an unusual cause of chest pain. Early detection of pneumo-pericardium and timely intervention while monitoring the patient in the ICU can prevent catastrophic outcomes. REFERENCE #1: Grandhi TM, Rawlings D, Morran CGGastropericardial fistula: a case report and review of literature Emergency Medicine Journal 2004;21:644-645. REFERENCE #2: Kato T, Mori T, Niibori K. A case of gastropericardial fistula of a gastric tube after esophagectomy: a case report and review. World J Emerg Surg. 2010 Jul 21;5:20. doi: 10.1186/1749-7922-5-20. PMID: 20663167; PMCID: PMC2917401. DISCLOSURES: No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Sana Hyder, source=Web Response no disclosure on file for Jason Jacob; No relevant relationships by Heather Swales, source=Web Response