Gastropericardial Fistula Research Articles

Gastropericardial fistula: A successfully operated heart code

Gastropericardial fistula is a rare, extremely serious and life-threatening condition. Its most common aetiology is secondary to iatrogenic injury following gastric surgery. Clinical manifestations may be non-specific with precordial pain, simulating an acute coronary syndrome, and may be accompanied by electrocardiogram abnormalities. Diagnosis is made by thoracoabdominal computed tomography (CT) with oral and intravenous contrast. Treatment is surgical and consists of repair of the anomalous communication. We present the case of an 81-year-old male patient with gastropericardial fistula who underwent surgery, with the aim of reviewing the diagnosis and the appropriate therapeutic strategy.

Gastropericardial fistula complicated by severe multi-vessel coronary spasm.

Gastropericardial fistula complicated by severe multi-vessel coronary spasm.

S4152 Gastro-gastric Fistula and Gastro-pericardial Fistula Presenting as Pneumopericardium and Pericarditis in a Patient with Roux-en-Y Gastric Bypass and NSAID Abuse

S4152 Gastro-gastric Fistula and Gastro-pericardial Fistula Presenting as Pneumopericardium and Pericarditis in a Patient with Roux-en-Y Gastric Bypass and NSAID Abuse

Pneumopericardium: A Rare Complication of Antireflux Surgery

Pneumopericardium is a rare clinical entity, occurring in the setting of thoracic trauma, malignancies, or mechanical ventilation. Very few cases report pneumopericardium as a complication of gastrointestinal tract surgery. Signs and symptoms may be frustrating, ranging from asymptomatic to chest pain, sepsis, hemodynamic instability, pericarditis, or even cardiac tamponade. Clinical pathognomonic signs of pneumopericardium include pericardial metallic tinkling friction rub and mill wheel murmur. Diagnostic work-up includes electrocardiogram, chest radiography, and, computed tomography imaging. A gastro pericardial fistula should be considered a rare differential diagnosis for acute chest pain in patients with a history of gastroesophageal surgery. Rapid recognition and treatment avoid life-threatening complications. The successful outcome of gastro pericardial fistula treatment depends on both emergency and definitive surgical management. The survival rate with conservative management is poor. We present the case of a 78-year-old patient suffering from pneumopericardium and pericardial infusion, due to a fibrotic fistula between the Nissen’s valve, occurring 10 years after redo antireflux surgery. Treatment included broad-spectrum antibiotics, and emergency surgery for pericardial drainage, biopsy of the valve’s defect, suture, and omentoplasty.

A017 Gastropericardial fistula after gastric bypass: Workup and management of a rare complex complication

A017 Gastropericardial fistula after gastric bypass: Workup and management of a rare complex complication

Fistula gastropericárdica: un código corazón operado con éxito

Gastropericardial fistula is a rare, extremely serious and life-threatening condition. Its most common etiology is secondary to iatrogenic injury following gastric surgery. Clinical manifestations may be non-specific with precordial pain, simulating an acute coronary syndrome, and may be accompanied by electrocardiogram abnormalities. Diagnosis is made by thoracoabdominal computed tomography (CT) with oral and intravenous contrast. Treatment is surgical and consists of repair of the anomalous communication. We present the case of an 81-year-old male patient with gastropericardial fistula who underwent surgery, with the aim of reviewing the diagnosis and the appropriate therapeutic strategy.

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

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.

Abstract 15867: A Swimming Heart: A Unique Complication of Gastropericardial Fistula

Background: Gastropericardial fistula is a rare clinical entity associated with gastroesophageal operations. Case: 63-year-old female with medical history of hypertension, GERD, and hiatal hernia status post Nissen fundoplication presented to the ER with one week of chest pain and dyspnea. Six months prior to presentation, she was found with ischemic colitis, candida esophagitis and slipped Nissen. In the ER, she was febrile and hypoxic. Chest x-ray showed a large hydropneumopericardium with air-fluid level. CT chest showed pneumomediastinum. Upon arrival to our facility, an echocardiogram showed normal EF 65% and a large complex pericardial effusion with presence of gas, liquid, and organized material without evidence of tamponade. Repeat CT abdomen showed a thin-walled collection of gas and fluid projecting from the area of the Nissen through the diaphragmatic hiatus in contact with the pericardium suspicious for a gastropericardial fistula. She went to the OR for pericardial window with drainage of 700 cc of purulent fluid and findings of chronic-appearing granulation of the pericardium. Intraoperative endoscopy noted a perforation near the GE junction that was stented with a 155 x 23 mm covered esophageal stent. Cultures grew Candida and gramnegative bacilli. She then underwent staged right thoracotomy with repair of fistula with intercostal muscle flap. Postoperative course was complicated with posterior wall hemorrhage requiring embolization of the left eight intercostal artery. The esophageal stent was removed three months post insertion due to distal migration causing superficial ulceration and esophagitis. Patient has since recovered gradually without further complications. Discussion: Gastropericardial fistula is associated with high morbidity and mortality. The treatment is surgical with early pericardial drainage usually by pericardial window and de-functioning esophagostomy or gastrostomy plus repair of the defect.

S3607 Gastropericardial Fistula as a Complication of a Perforated Marginal Ulcer in a Patient With Roux-en-Y Gastric Bypass Surgery

S3607 Gastropericardial Fistula as a Complication of a Perforated Marginal Ulcer in a Patient With Roux-en-Y Gastric Bypass Surgery

A187 Perforated Marginal Ulcer Resulting in a Gastropericardial Fistula: Endoscopic Management of a Rare Complication After Roux-en-Y Gastric Bypass

A187 Perforated Marginal Ulcer Resulting in a Gastropericardial Fistula: Endoscopic Management of a Rare Complication After Roux-en-Y Gastric Bypass

Gastropericardial Fistula as a Life-Threatening Complication after Intragastric Balloon Insertion

Laparoscopic bariatric surgery, while highly effective, is an invasive method for sustainable weight loss [1]. Less than 1% of patients with clinically severe obesity undergo bariatric surgery [2], in part because of concerns regarding surgical complications [3].

A Case of Conservatively Treated Gastropericardial Fistula due to a Reconstructed Gastric Tube Ulcer after Esophagectomy for Cancer

A Case of Conservatively Treated Gastropericardial Fistula due to a Reconstructed Gastric Tube Ulcer after Esophagectomy for Cancer

Abstract 11762: The Proximity of the Stomach to the Inferior Wall of the Heart: Implications for Non-Invasive Radio-Ablation of Ventricular Tachycardia

Introduction: Stereotactic ablative radiotherapy is a promising therapy for ventricular tachycardia (VT), but the formation of gastro-pericardial fistula is a serious complication associated with this procedure. The proximity of the stomach to the heart has not been well characterized. Hypothesis: We hypothesized that the stomach is located in close proximity (<1cm) to the inferior cardiac wall. Methods: Patients who underwent 4D cardiac computed tomography (4DCT) prior to a catheter ablation procedure for atrial or ventricular arrhythmias at 2 medical centers were studied retrospectively. 4DCT was acquired using cardiac-gated Siemens Force or GE Revolution scanners. The closest distance from the stomach or esophagus to the left ventricular (LV) myocardium was measured during both end systole and diastole (Fig 1) using imaging analysis software (Horos Project, Annapolis, MD). Clinical predictors of close proximity were assessed using Student’s t-test, Chi-squared and Pearson’s linear regression. Results: In 42 patients (age 65±11.4 years, VT/PVC ablation in 21/42 patients, 50%), the mean gastric proximity was 7.5±4.2mm during end-systole and 6.1±3.6mm during end-diastole (p=0.12). Smaller gastric proximity was significantly associated with increasing LV diameter (y=-1.376*x +12.55; p=0.03) or a history of coronary artery disease (4.8±2.2mm vs 8.3±4.4mm, p=0.02). The closest proximity of the stomach was found most frequently in the mid-segment (compared to the basal or apical segments of the inferior wall, p<0.0001). Conclusions: In patients with arrhythmias, the stomach is located within a mean of 6mm to the mid-inferior wall of the LV, with closer proximity in patients with dilated hearts. Careful avoidance of the stomach is critical during radio-ablative therapy of VT to avoid complications, particularly in patients with mid-inferior wall targets and dilated hearts. Studies are ongoing to study motion management strategies to improve precision.

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

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

Case report of a 72-year-old man with diaphragmatic hernia and thoracic gastropericardial fistula after esophagectomy for 18\u2009years

BackgroundBoth diaphragmatic hernia and thoracic gastropericardial fistula rarely occur simultaneously in patients with radical esophagectomy.Case presentationA 72-year-old man presented to our hospital with 1 day of nausea, vomiting and acute left chest pain. He had radical esophagectomy (Sweet approach) for esophageal cancer 18 years ago. Computed tomography (CT) of the chest revealed diaphragmatic hernias and air collection within the pericardial space. While an operation of diaphragmatic hernia repair was decisively performed to prevent further serious complications, unusually, a thoracic gastropericardial fistula was also found unusually.ConclusionDiaphragmatic hernia and thoracic gastropericardial fistula may occasionally coexist in patients with esophagectomy. Upper GI radiograph with a water-soluble contrast agent is a better diagnostic tool than CT in visualizing the fistula.

Effusive–constrictive pericarditis secondary to pneumopericardium associated with gastropericardial fistula

A 66‐year‐old man with a history of gastric pull‐up reconstruction for oesophageal cancer was hospitalized because of prolonged chest pain. Chest X‐ray demonstrated pneumopericardium. Computed tomography revealed ulceration and abscess in the gastric conduit adjacent to the heart, suggesting gastropericardial fistula. As the patient did not show tamponade physiology, he was conservatively treated with antibiotics. The pneumopericardium diminished; however, he developed effusive–constrictive pericarditis with overt heart failure symptoms. Because pericardiocentesis failed to relieve the symptoms, pericardiectomy was performed. Intraoperative exploration revealed remarkably thickened pericardium and epicardium constituting multiple layers with purulent effusion. Epicardiectomy as well as pericardiectomy were required to achieve the effective reduction of central venous pressure. Perforation of the gastric conduit into the pericardial cavity was identified and repaired. Histopathology demonstrated thickened pericardium composed of hyalinized stroma, collagenous bundles, and infiltration of inflammatory cells. Streptococcus anginosus and Candida tropicalis were identified by culture of the resected tissue.

Delayed gastropericardial fistula following gastric pull-up

Abstract Gastro-pericardial fistula (GPF) is a rare condition, caused by trauma, benign or malignant pathology. Rare case of delayed complication of retrosternal gastric conduit for esophageal atresia presenting 18 years after surgery as GPF is discussed. Thoracoscopic excision of GPF was done. Treatment strategies for GPF require drainage of pericardium, fistula resection, defunctioning esophagostomy/gastrostomy. Thoracoscopy is better modality to manage such cases avoiding morbidity of sternotomy in moribund patient. While operating pediatric patients for gastric conduit advantage of reduced incidence of GPF in posterior mediastinal placement should be considered, because GPF might manifest as late as 18–20years.

Purulent Pericarditis with Cardiac Tamponade Secondary to Candida Albicans after Total Parenteral Nutrition: A Case Report

Purulent pericarditis is characterized by a purulent pericardial fluid, which usually originates from the extension of a nearby bacterial infection site or by blood dissemination. Candida species is a rare cause of pericarditis; and if not treated, it is extremely fatal. In this report, we describe a 54-year-old man who had esophagojejunostomy due to gastric adenocancer 2 months before his admission into our emergency department with dyspnea, orthopnea, chest pain, and somnolence. Physical and echocardiographic examinations revealed massive fibrinous pericardial effusion, causing pericardial tamponade. We performed urgent pericardiocentesis. The culture of the purulent pericardial fluid illustrated Candida albicans. There was no gastropericardial fistula after endoscopic and computed tomographic evaluations of the gastrointestinal tract. After receiving 1 month of antimicrobial treatment, the patient recovered completely. During his follow-up, he remained asymptomatic and had no pericardial fluid for 6 months. Our case indicates the possibility of the occurrence of purulent pericarditis with tamponade, secondary to the dissemination of Candida albicans from total parenteral nutrition after gastric carcinoma surgery without gastropericardial fistulae or anastomosis leak.

Gastropericardial fistula: a case report

Rationale: Gastropericardial fistula is a rare condition in which the patient presented with chest pain, dyspnea, tachycardia, pneumo/hydropericardium, or pericarditis. Alcohol intake or previous history of gastroesophageal surgery made the patient susceptible to fistula formation. Patient concerns: An 80-year-old male complained of sudden onset of dyspnea and respiratory distress. Nausea, hematemesis, and constipation were noted on clinical examination. Diagnosis: Herniation of the gastric fundus and massive pneumopericardium due to formation of fistula in the lesser curvature. Interventions: Urgent surgery was performed. Outcomes: The patient was discharged without any complication.Lessons: Although the lethal form of this condition is rare, gastroepicardial fistula should be included in the differential diagnosis workup of cases with stomach cardia and fundus ulceration.

Gastropericardial fistula: A rare etiology of chest pain

Gastropericardial fistula is an abnormal communication between the stomach and the pericardium. It is a rare, life-threatening condition that has numerous etiologies. We report the case of a 53-year-old male patient, with a history of wedge resection for gastrointestinal stromal tumor, who presented to the emergency department for epigastric and chest pain along with lethargy leading to the uncommon diagnosis of gastropericardial fistula with pneumopericardium. Through this case, we would like to draw clinicians’ attention to gastropericardial fistula as a differential diagnosis in patients presenting for epigastric and/or chest pain with a history of esophagogastric surgery, emphasizing on the key role of computed tomography in this regard, and underscore the management basics of this unusual condition.