A Patient with Chest Pain

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A PATIENT WITH CHEST PAIN Katia Kaplan-List. M.D, M.A. INITIAL CHEST RADIOGRAPH CAUSES OF PNEUMOPERICARDIUM • Penetrating trauma, e.g. stab wound • Blunt trauma, e.g. high speed MVC • Barotrauma, usually infants on high ventilator pressure • Pericarditis due to gas forming organisms • Intrapericardial perforation of lung abscess or tuberculosis cavity • Perforated benign or malignant ulcers with bronchopericardial, esophagopericardial, and gastropericardial fistulae • Pneumopericardium has been reported to occur from sub- diaphragmatic lesions namely anaerobic and pyogenic liver abscesses that have penetrated through the diaphragm • Foreign body aspiration • Vigorous Valsalva, e.g. during sports, drug use • Acute asthma • IATROGENIC CAUSES OF PNEUMOPERICARDIUM • Sternal bone marrow puncture • Thoracic surgery • Thoracocentesis and pericardiocentesis • Dental extraction • Endoscopic procedures • Laparoscopy INITIAL CHEST CT INITIAL CHEST CT INITIAL CHEST CT INITIAL ABDOMINAL CT INITIAL ABDOMINAL AND CHEST CT INITIAL ABDOMINAL CT UPPER GI SERIES CHEST RADIOGRAPH DAY 2 CHEST RADIOGRAPH DAY 5 CHEST RADIOGRAPH DAY 8 CT ABDOMEN DAY 11 Pericardial drain Pericardial effusion CT ABDOMEN DAY 11 Pericardial drain Abdominal drain Oral contrast ESOPHAGRAM DAY 11 CHEST RADIOGRAPH DAY 13 CHEST RADIOGRAPH DAY 21 GASTROPERICARDIAL FISTULA Gastropericardial fistula is a rare sequel of transdiaphragmatic perforation of a gastric ulcer or carcinoma. The stomach is usually intra-thoracic: • hiatus hernia • diaphragmatic hernia • after oesophagectomy with gastric pull-up Trans-diaphragmatic perforation of a gastric carcinoma or ulcer into the pericardium, particularly in Zollinger-Ellison Syndrome, may also occur with an intra-abdominal stomach. CONCLUSION Gastropericardial fistula is a rare condition with high mortality Requires a high index of suspicion, early diagnosis and prompt surgical intervention for a favorable outcome Surgery is the definite treatment as patients rarely survive with conservative management Definitive management includes resection of the fistula, repair of the diaphragmatic defect and dealing with the primary pathology of stomach REFERENCES 1. Mirvis SE, Indeck M, Schorr RM et-al. Posttraumatic tension pneumopericardium: the "small heart" sign. Radiology. 1986;158 (3): 663-9. 2. Karoui M, Bucur PO. Images in clinical medicine. Pneumopericardium. N. Engl. J. Med. 2008;359 (14): e16. 3. Capizzi PJ, Martin M, Bannon MP. Tension pneumopericardium following blunt injury. J Trauma. 1995;39 (4): 775-80. 4. Spontaneous Pneumopericardium Due to Exertion Gerald W. Westermann, MD, Barbara Suwelack, MD South Med J. 2003;96(1) 5. S Sahu, S Agarwal, P Sachan, D Bahl. Gastropericardial Fistula: A Surgical Emergency. The Internet Journal of Surgery. 2006 Volume 13 Number 2. THANK YOU! .

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Hemodynamic Assessment of Pneumopericardium by Echocardiography
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