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Pneumopericardium is a rare occurrence. A variety of oesophageal and gastric lesions have been reported to perforate into the pericardium causing pneumopericardium. Although peptic ulceration in hiatus hernia has also been reported to perforate into pericardium, other types of diaphragmatic hernia have not been described as causing perforation into the pericardium. We report a case of a young man who presented with chest pain and was found to have pneumopericardium secondary to a gastropericardial fistula in a recurrent diaphragmatic hernia.
A 29 year old man presented in March 2002 to the accident and emergency department with two hour history of severe chest and abdominal pain and dyspnoea. He was in severe pain with a pulse rate of 112/min, blood pressure 169/74 mm Hg, and respiratory rate of 26/min. Resuscitation was begun with oxygen, intravenous fluids, and analgesics. On examination he had decreased air entry at left chest base, tenderness, and guarding in upper abdomen and an upper midline scar. Chest radiography showed pneumopericardium (fig 1). Electrocardiogram showed sinus tachycardia and 1 mm ST segment elevation in V2 and V3. Blood investigations showed a white cell count of 29.1×109/l. Blood gas analysis showed respiratory acidosis with pH of 7.26 and Paco2 of 7.11 kPa. He was in excruciating pain with persistent tachycardia and tachypnoea and had to receive a total of 55 mg of intravenous morphine in titrated doses. Repeat examination showed distended neck veins. Repeat chest radiography showed increase in the size of pneumopericardium suggesting cardiac tamponade. Pericardiocentesis was done by subxiphoid approach under local anaesthesia with 1% lignocaine (lidocaine) and 60 ml of air was aspirated. This resulted in immediate clinical improvement and the pulse and blood pressure gradually returned to normal. A contrast meal using Gastromiro showed the presence of diaphragmatic hernia with perforation of stomach into pericardial sac (fig 2). Thus a diagnosis of gastropericardial fistula secondary to perforation of the stomach in diaphragmatic hernia was made.
In December 1997 he sustained a stab injury and developed a left pneumothorax, which was treated with chest drain uneventfully. In January 2000 laparotomy for peritonitis revealed a diaphragmatic hernia containing stomach, which was repaired. Over the next year he presented 10 times to the A&E department with episodes of a recurrent pain in his left shoulder. Examination and investigations for local and referred pain at the left shoulder included radiography of left shoulder, CT arthrogram of left shoulder joint, and ultrasound scan of the abdomen all of which were normal.
On this admission through a combination of laparotomy and left anterolateral thoracotomy the fistula was disconnected, and the defects in the stomach and diaphragm were repaired. Splenectomy was needed to gain access to the diaphragmatic defect. At follow up at one year he had no recurrence of his symptoms, in particular his left shoulder pain resolved completely.
Pneumopericardium is a rare but well recognised entity. Britcheteau first described it in 1844.1 The causes are of two groups: traumatic and non-traumatic, most being traumatic. Injuries account for most cases in the traumatic group. Less common causes in this group include thoracic procedures, endoscopy, and positive pressure ventilation. Predominant causes in the non-traumatic group include acute asthma and the oesophageal lesions namely peptic ulceration, carcinoma, and spontaneous rupture. Less common causes in this group include intrapericardial perforation of lung abscess or tuberculosis cavity and pericarditis attributable to gas forming organisms. Pneumopericardium has been reported to occur from sub-diaphragmatic lesions namely anaerobic and pyogenic liver abscesses that have penetrated through the diaphragm. Gastropericardial fistula resulting from peptic ulcer and carcinoma is the cause of pneumopericardium in less than 15 cases. The stomach in these cases was usually intrathoracic, through the hiatus as a hernia or after oesophagogastrectomy.2–5 Pneumopericardium can also occur after trans-diaphragmatic perforation of gastric carcinoma or ulcer into the pericardium,6–8 particularly in the presence of Zollinger-Ellison syndrome.2,8
Pain in the left shoulder was thought to be a symptom of pericardial irritation in few previous case reports.4 Our patient presented to A&E department on numerous occasions with the same symptom. This was attributed to some local cause in the left shoulder, but probably represented diaphragmatic irritation. The diagnostic criteria of hydropneumopericardium as described by Shackelford in 19311,2 are (a) a high pitched tympanitic percussion note, (b) a loud metallic splashing sound synchronously with the heart sounds, and (c) a characteristic chest radiograph with an air fluid level in the pericardial cavity.
Most cases of pneumopericardium have been diagnosed by chest radiography. Contrast radiography showed if a hiatal or other type of diaphragmatic hernia was present, and whether an oesophageal or gastric ulcer was present. The precise cause can be found in 70% of cases.9 Computed tomography may be helpful if the cause is not evident on contrast radiography. Oesophago-gastro-duodenoscopy (OGD), although used in a few cases,6,7,9,10 should be used with caution, as insufflation of air exacerbates cardiac tamponade.5 ECG may show changes of atrial fibrillation or pericarditis.9,10 but will be normal in most patients.
Only two cases have been reported to survive after conservative treatment with pericardiocentesis and antibiotics.6,9 The emergency management of pneumopericardium is twofold—firstly, early recognition of its presence by plain chest radiography and secondly, detection of signs of cardiac tamponade. Pericardial decompression is a lifesaving emergency measure in the presence of cardiac tamponade. Delay in intervention in these cases can be life threatening. Surgery is the definitive treatment of pneumopericardium irrespective of the cause and location of the fistula.4,5,7 Successful outcome of gastropericardial fistula depends on both the emergency and definitive managements. Emergency management includes early recognition of pneumopericardium and pericardial decompression. Definitive management is resection of fistula and repair of diaphragmatic hernia. Adequate exposure and effective repair of the diaphragmatic defect may require splenectomy.8
In our case the initial injury to the diaphragm probably occurred at the time of stab injury. This defect in the diaphragm was asymptomatic until it declared itself as diaphragmatic hernia two years later. We have been unable to find a similar case in literature. Our patient underwent pericardial decompression within an hour and surgery with in three hours of presentation to the hospital. Our case emphasises the importance of lifesaving measures in the emergency management of pneumopericardium namely, early recognition of pneumopericardium and emergency pericardial decompression in suspected cases of tamponade.