A Case of Pneumopericardium as a Late Complication of Gastric Bypass Surgery
2014; Lippincott Williams & Wilkins; Volume: 130; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.114.007237
ISSN1524-4539
AutoresJef Huyskens, Elisabeth Macken, Josephus Schurmans, Paul M. Parizel, Rodrigo Salgado,
Tópico(s)Esophageal and GI Pathology
ResumoHomeCirculationVol. 130, No. 18A Case of Pneumopericardium as a Late Complication of Gastric Bypass Surgery Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBA Case of Pneumopericardium as a Late Complication of Gastric Bypass Surgery Jef Huyskens, MD, Elisabeth Macken, MD, Josephus Schurmans, MD, Paul P.M. Parizel, MD PhD and Rodrigo Salgado, MD Jef HuyskensJef Huyskens From the Antwerp University Hospital, Antwerp, Belgium (J.H., E.M., P.P.M.P., R.S.); and AZ St.-Dimpna, Geel, Belgium (J.S.). , Elisabeth MackenElisabeth Macken From the Antwerp University Hospital, Antwerp, Belgium (J.H., E.M., P.P.M.P., R.S.); and AZ St.-Dimpna, Geel, Belgium (J.S.). , Josephus SchurmansJosephus Schurmans From the Antwerp University Hospital, Antwerp, Belgium (J.H., E.M., P.P.M.P., R.S.); and AZ St.-Dimpna, Geel, Belgium (J.S.). , Paul P.M. ParizelPaul P.M. Parizel From the Antwerp University Hospital, Antwerp, Belgium (J.H., E.M., P.P.M.P., R.S.); and AZ St.-Dimpna, Geel, Belgium (J.S.). and Rodrigo SalgadoRodrigo Salgado From the Antwerp University Hospital, Antwerp, Belgium (J.H., E.M., P.P.M.P., R.S.); and AZ St.-Dimpna, Geel, Belgium (J.S.). Originally published28 Oct 2014https://doi.org/10.1161/CIRCULATIONAHA.114.007237Circulation. 2014;130:1633–1635A 61-year-old man who underwent gastric bypass surgery 4 years earlier presented at the emergency department with acute interscapular pain. His cardiac enzymes were normal, and an ECG examination showed concave ST-segment elevations in the inferior area (II, III, and aVF), suggestive of acute pericarditis.An initial plain chest radiograph revealed the presence of air between the left heart shadow and the pleura, highly suggestive of a pneumomediastinum (Figure 1).1Download figureDownload PowerPointFigure 1. Plain posterior-anterior (PA) and lateral chest radiograph shows the presence of air (arrow) between the pleura and left border (PA) and anterior (lateral) of the heart.A subsequent computed tomography examination confirmed a pneumopericardium with an air-fluid level in the pericardial space (Figure 2). At this moment, the spectrum of findings gathered thus far pointed to a high clinical suspicion of a low-esophageal or high-gastric rupture.1,2 Because of the fear of inducing a cardiac tamponade by performing a transesophageal ultrasound of the heart, the patient was again referred for a second computed tomography examination several hours later that night.2 To improve the detection of a potential esophageal or gastric rupture, this new computed tomography scan was performed 30 seconds after oral ingestion of a water-soluble iodinated contrast agent.3–6Download figureDownload PowerPointFigure 2. Axial computed tomography examination of the thoracic space after the injection of intravenous contrast shows the presence of air in the pericardial space (arrow), visible with a soft tissue window (A) and more clearly visible with a lung window (B).In this second computed tomography examination, pericardial fluid with a now abnormally high density was seen in addition to the previous findings (Figure 3), indicating passage of the orally ingested contrast agent into the pericardium.4,5 Further close examination of the computed tomography images revealed a contrast-filled fistula between the gastroenteric anastomosis and the pericardium (Figures 4 and 5).Download figureDownload PowerPointFigure 3. Axial computed tomography examination of the thoracic space after the injection of intravenous contrast and ingestion of oral contrast shows the presence of air in the pericardial space (B, black arrow) and an air-fluid level with an abnormally high fluid density (A, white arrow).Download figureDownload PowerPointFigure 4. Coronal reconstructed computed tomography examination shows a fistula between the pericardial space and stomach pouch with oral contrast flowing in the pericardial space (black arrow). Note also the presence of air in the pericardial space (white arrowhead) and in the pericardial recess (black arrowhead) and the presence of high-density pericardial fluid.Download figureDownload PowerPointFigure 5. Sagittal maximal-intensity projection reconstructed computed tomography examination shows the fistula with oral contrast flowing from the pouch in the pericardial space (white arrow). Note also the presence of air in the pericar dial space and recess (white arrowheads).These findings were subsequently confirmed by direct gastroscopy, during which a perforated ulcer in the stomach pouch was identified as the entry point of the fistula.2 The patient underwent successful surgical closing of this gastropericardial fistula and was discharged 2 weeks later after an uneventful recovery. To the best of our knowledge, only 1 previous report has described a pneumomediastinum caused by a gastropericardial fistula long after gastric bypass surgery.6We point out this possible complication after elective obesity surgery because this patient population has a long-term survival after surgery.DisclosuresNone.FootnotesCorrespondence to Jef Huyskens, MD, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium. E-mail [email protected]References1. Zylak CM, Standen JR, Barnes GR, Zylak CJ. Pneumomediastinum revisited.Radiographics. 2000; 20:1043–1057.CrossrefMedlineGoogle Scholar2. Restrepo CS, Lemos DF, Lemos JA, Velasquez E, Diethelm L, Ovella TA, Martinez S, Camillo J, Moncada R, Klein JS. Imaging findings in cardiac tamponade with the emphasis on CT scan.Radiographics. 2007; 27:1595–1610.CrossrefMedlineGoogle Scholar3. Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation.Radiology. 2002; 224:9–23.CrossrefMedlineGoogle Scholar4. Grandhi TM, Rawlings D, Morran CG. Gastropericardial fistula: a case report and review of literature.Emerg Med J. 2004; 21:644–645.CrossrefMedlineGoogle Scholar5. Müller AM, Betz MJ, Kromeier J, Ghanem NA, Geibel A, Imdahl A, Frydrychowicz AP. Images in cardiovascular medicine: acute pneumopericardium due to intestino-pericardial fistula.Circulation. 2006; 114:e7–e9.LinkGoogle Scholar6. Rodriguez D, Heller MT. Pneumopericardium due to gastropericardial fistula: a delayed, rare complication of gastric bypass surgery.Emerg Radiol. 2013; 20:333–335.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lam K, Tan E, Spilias D and Gribbin J (2019) Rare case of a gastro‐pericardial fistula after gastric bypass surgery, ANZ Journal of Surgery, 10.1111/ans.15620, 90:7-8, (1514-1517), Online publication date: 1-Jul-2020. Strong A and Kroh M (2018) Identification and Treatment of Fistulas and Chronic Cavities Endoscopy in Obesity Management, 10.1007/978-3-319-63528-6_9, (89-104), . October 28, 2014Vol 130, Issue 18 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.114.007237PMID: 25462824 Originally publishedOctober 28, 2014 PDF download Advertisement SubjectsComputerized Tomography (CT)
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