- Email: [email protected]
Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors
Clinical Imaging xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors Joshua J. Reicher ⁎, Robert Mindelzun Stanford Hospital & Clinics, Department of Radiology, 300 Pasteur Dr., H1307 MC 5621, Stanford, CA 94305
a r t i c l e
i n f o
Article history: Received 25 December 2013 Accepted 3 February 2014 Available online xxxx Keywords: Gastropericardial fistula Pneumopericardium Gastric ulcer
a b s t r a c t A 53-year-old homeless male presented to the emergency department with sudden onset chest pain and was found to have a large pneumopericardium on chest X-ray. The patient had no history of surgery, hiatal hernia, or ulcer disease. A contrast-enhanced computed tomography scan demonstrated the pneumopericardium and raised concern for possible gastropericardial fistula from a benign gastric ulcer. An esophagogastroduodenoscopy confirmed the fistula, as did surgery, and intraoperatively vegetable particular matter was removed from the anatomic space continuous with the pericardium. Published by Elsevier Inc.
1. Case description A 53-year-old homeless male with a history of alcohol abuse presented to the emergency department with new sudden onset chest pain. The patient was noted to be mildly tachycardic but afebrile, and initial laboratory measurements including blood count and cardiac markers were normal. An electrocardiogram was negative. A twoview chest X-ray revealed a pneumopericardium of unknown etiology (Fig. 1). A contrast-enhanced computed tomography (CT) scan of the chest and abdomen demonstrated a massive pneumopericardium (Fig. 2A). In addition, possible loss of a distinct tissue plane between a small region in the cardia of the stomach, the diaphragm, and in the inferior aspect of the pericardium was noted, raising the question of a gastropericardial fistula (Fig. 2B–G). On the lesser curvature of the gastric fundus, there was a deep ulcer with heaped-up symmetrical mucosa and an ectopic gas collection in its center, compatible with benign ulceration. No evidence of lymphadenopathy or other signs of malignancy were found. The patient had no history of surgery, hiatal hernia, or ulcer disease. Given the imaging findings, the patient was transferred for a higher-level care for management of a possible gastropericardial fistula. On transfer, the patient developed a fever to 102°F, and repeat laboratory studies were notable for an elevated white blood cell count of 16.6 (10 3/uL). Antibiotics were administered, and an urgent esophagogastroduodenoscopy (EGD) was performed. Pertinent findings included signs of mild gastritis as well as an approximately 2.0-cm benign-appearing ulcer in the gastric cardia with a small ⁎ Corresponding author. Stanford Hospital & Clinics, Department of Radiology, 300 Pasteur Dr., H1307 MC 5621, Stanford, CA 94305. Tel.: +1 650 723 8463; fax: 1 650 723 1909. E-mail address: [email protected] (J.J. Reicher).
central perforation. From the perforated center, serous fluid was noted emanating into the stomach in a pulsatile fashion synchronous with the patient's heartbeat, confirming the diagnosis of gastropericardial fistula. The patient was taken to surgery and underwent a partial proximal gastrectomy, splenectomy, and subxiphoid pericardial window. During the procedure, a large region of dense, fibrotic scar tissue was identified at the esophageal hiatus, involving the proximal stomach, diaphragm, and pericardium. The pericardium was noted to be thickened and inflamed, and serous fluid as well as vegetable particulate matter reportedly appearing to include pieces of onion was removed from this continuous space involving the pericardium. Postoperatively the patient had a complicated hospital course including multiple take-backs to the operating room for septic shock and peritonitis. At the time of this composition, the patient remained in critical condition. 2. Discussion Gastropericardial fistula is a rare and typically fatal entity, with an estimated 44 cases reported within the English-language literature through 2012 [1]. These fistulae typically present as a late complication of prior esophagectomy, fundoplication, or diaphragmatic hernia repair, though they can also arise from malignancy. Fewer cases arise from a perforated gastric ulcer within a hiatal hernia, usually in patients with significant ulcer disease related to non-steroidal antiinflammatory drugs (NSAIDs) or Zollinger–Ellison syndrome [2]. In 1998 a case report of a 58-year-old female with benign ulcer leading to gastropericardial fistula was published as the first reported case of such a complication in a patient with no surgical history and no history of hiatal hernia, though the patient was taking alendronate (known to cause gastric ulcers) and did suffer from known peptic
0899-7071/$ – see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.clinimag.2014.02.005
Please cite this article as: Reicher JJ, Mindelzun R, Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.02.005
2
J.J. Reicher, R. Mindelzun / Clinical Imaging xxx (2014) xxx–xxx
pericardial fistula [5]. The clinical presentation of gastropericardial fistula is variable and can include chest pain, fever, and tachycardia as in the subject of this case report, but also dyspnea, dysphagia, and cardiac tamponade [5]. The initial differentiating feature for these otherwise nonspecific symptoms is typically a chest radiograph, which readily demonstrates air within the pericardial space, visualized as sharp outlining of the pericardium by air on both sides. Pneumopericardium is radiographically distinguished from pneumomediastinum by its superior limit at the pericardial reflection at the root of the aorta and main pulmonary artery. Spontaneous atraumatic pneumopericardium on a chest radiograph is an uncommon finding but should stimulate investigation for an underlying etiology. In particular, in patients with risk factors for entero-pericardial fistula including prior esophageal surgery, prior diaphragmatic hernia repair, significant ulcer disease, or gastrointestinal malignancy, suspicion for a finding of an underlying fistula should be high. Contrast-enhanced CT scan is useful and may demonstrate disruption of normal tissue planes, a suspected fistula track, and dissecting air [3]. Others recommend an upper gastrointestinal (GI) tract series with water-soluble contrast for initial evaluation in stable patients [5]. While endoscopy can assist in diagnosis, some recommend avoiding endoscopy if possible given the potential risk for inducing or worsening cardiac tamponade with the introduction of additional air into the stomach [6]. For treatment, though a few cases of successful conservative management have been reported, a more common consensus recommends early diagnosis and surgical management when possible [7,8]. Because mortality rates have been reported to be as high as 85%, early detection followed by timely surgery is generally recommended [8]. 3. Ethical standards No experimental research was performed in the development of this manuscript. Acknowledgments Fig. 1. Two-view chest X-ray with anteroposterior (AP) and lateral views demonstrating a large pneumopericardium.
None. References
ulcer disease for which she was receiving treatment [3]. Thus, the case described herein is somewhat unique in that this 53-year-old patient had no known history of hernia, no prior surgeries, and no history of ulcer disease, except for the single ulcer discovered on the ensuing EGD that otherwise revealed mild gastritis and no additional ulcers. Interestingly, the location of the ulcer is notably similar to that of the case reported in 1998. Historically, cases of perforated gastric fundus ulcers leading to subphrenic abscesses that subsequently dissected through the diaphragm and into the pericardium have been reported, though the time course is typically subacute rather than acute [4]. Patients with gastropericardial fistula have typically been treated surgically with a high mortality, though case reports of survival nonoperatively have been published [1,3]. Pneumopericardium itself is relatively uncommon, though it can be apparent after cardiac surgery or as a complication of trauma, esophageal ulceration, or a variety of other causes, including entero-
[1] Imran Hamid U, Booth K, McManus K. Is the way to a man's heart through his stomach? Enteropericardial fistula: case series and literature review. Dis Esophagus Jul 2013;26(5):457–64. http://dx.doi.org/10.1111/j.1442-2050.2012.01373.x. [2] Park S, Kim JH, Lee YC, Chung JB. Gastropericardial fistula as a complication in a refractory gastric ulcer after esophagogastrostomy with gastric pull-up. Yonsei Med J March 1 2010;51(2):270–2. [3] Chapman PR, Boals JR. Pneumopericardium caused by giant gastric ulcer. AJR Am J Roentgenol Dec 1998;171(6):1669–70. [4] Reisberg IR. Endoscopic antemortem diagnosis of gastropericardial fistula caused by perforation of benign gastric ulcer. Gastrointest Endosc Aug 1974;21(1):27–9. [5] Simice P, Zwirewich CV. Gastropericardial fistula complicating benign gastric ulcer: case report. Can Assoc Radiol J Aug 2000;51(4):244–7. [6] Ruano Poblador A, Gay Fernández AM, García Martínez MT, et al. Pneumopericardium caused by gastropericardial fistula. Rev Esp Enferm Dig Mar 2007;99(3): 168–71. [7] Grandhi TM, Rawlings D, Morran CG. Gastropericardial fistula: a case report and review of the literature. Emerg Med J 2004;21:644–5. http://dx.doi.org/10.1136/ emj.2003.007765. [8] Letoquart JP, Fasquel JL, L'Huillier JP, Babatasi G, et al. Gastropericardial fistula. Review of the literature apropos of an original case. J Chir (Paris) Jan 1990;127(1): 6–12.
Please cite this article as: Reicher JJ, Mindelzun R, Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.02.005
J.J. Reicher, R. Mindelzun / Clinical Imaging xxx (2014) xxx–xxx
3
Fig. 2. Contrast-enhanced CT of the chest and abdomen. (A) Redemonstration of a large pneumopericardium; (B), (C), (D), (E) Subtle loss of a distinct tissue plane (arrow) between the cardia of the stomach, the diaphragm, and the inferior aspect of the pericardium, with apparent tracking of air in this region. On the lesser curvature of the gastric fundus, note the deep ulcer with heaped-up symmetrical mucosa and an ectopic gas collection in its center, compatible with benign ulceration. (F), (G) Demonstration of the same findings (arrow) in coronal (F) and sagittal (G) reconstructions.
Please cite this article as: Reicher JJ, Mindelzun R, Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.02.005
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors Joshua J. Reicher ⁎, Robert Mindelzun Stanford Hospital & Clinics, Department of Radiology, 300 Pasteur Dr., H1307 MC 5621, Stanford, CA 94305
a r t i c l e
i n f o
Article history: Received 25 December 2013 Accepted 3 February 2014 Available online xxxx Keywords: Gastropericardial fistula Pneumopericardium Gastric ulcer
a b s t r a c t A 53-year-old homeless male presented to the emergency department with sudden onset chest pain and was found to have a large pneumopericardium on chest X-ray. The patient had no history of surgery, hiatal hernia, or ulcer disease. A contrast-enhanced computed tomography scan demonstrated the pneumopericardium and raised concern for possible gastropericardial fistula from a benign gastric ulcer. An esophagogastroduodenoscopy confirmed the fistula, as did surgery, and intraoperatively vegetable particular matter was removed from the anatomic space continuous with the pericardium. Published by Elsevier Inc.
1. Case description A 53-year-old homeless male with a history of alcohol abuse presented to the emergency department with new sudden onset chest pain. The patient was noted to be mildly tachycardic but afebrile, and initial laboratory measurements including blood count and cardiac markers were normal. An electrocardiogram was negative. A twoview chest X-ray revealed a pneumopericardium of unknown etiology (Fig. 1). A contrast-enhanced computed tomography (CT) scan of the chest and abdomen demonstrated a massive pneumopericardium (Fig. 2A). In addition, possible loss of a distinct tissue plane between a small region in the cardia of the stomach, the diaphragm, and in the inferior aspect of the pericardium was noted, raising the question of a gastropericardial fistula (Fig. 2B–G). On the lesser curvature of the gastric fundus, there was a deep ulcer with heaped-up symmetrical mucosa and an ectopic gas collection in its center, compatible with benign ulceration. No evidence of lymphadenopathy or other signs of malignancy were found. The patient had no history of surgery, hiatal hernia, or ulcer disease. Given the imaging findings, the patient was transferred for a higher-level care for management of a possible gastropericardial fistula. On transfer, the patient developed a fever to 102°F, and repeat laboratory studies were notable for an elevated white blood cell count of 16.6 (10 3/uL). Antibiotics were administered, and an urgent esophagogastroduodenoscopy (EGD) was performed. Pertinent findings included signs of mild gastritis as well as an approximately 2.0-cm benign-appearing ulcer in the gastric cardia with a small ⁎ Corresponding author. Stanford Hospital & Clinics, Department of Radiology, 300 Pasteur Dr., H1307 MC 5621, Stanford, CA 94305. Tel.: +1 650 723 8463; fax: 1 650 723 1909. E-mail address: [email protected] (J.J. Reicher).
central perforation. From the perforated center, serous fluid was noted emanating into the stomach in a pulsatile fashion synchronous with the patient's heartbeat, confirming the diagnosis of gastropericardial fistula. The patient was taken to surgery and underwent a partial proximal gastrectomy, splenectomy, and subxiphoid pericardial window. During the procedure, a large region of dense, fibrotic scar tissue was identified at the esophageal hiatus, involving the proximal stomach, diaphragm, and pericardium. The pericardium was noted to be thickened and inflamed, and serous fluid as well as vegetable particulate matter reportedly appearing to include pieces of onion was removed from this continuous space involving the pericardium. Postoperatively the patient had a complicated hospital course including multiple take-backs to the operating room for septic shock and peritonitis. At the time of this composition, the patient remained in critical condition. 2. Discussion Gastropericardial fistula is a rare and typically fatal entity, with an estimated 44 cases reported within the English-language literature through 2012 [1]. These fistulae typically present as a late complication of prior esophagectomy, fundoplication, or diaphragmatic hernia repair, though they can also arise from malignancy. Fewer cases arise from a perforated gastric ulcer within a hiatal hernia, usually in patients with significant ulcer disease related to non-steroidal antiinflammatory drugs (NSAIDs) or Zollinger–Ellison syndrome [2]. In 1998 a case report of a 58-year-old female with benign ulcer leading to gastropericardial fistula was published as the first reported case of such a complication in a patient with no surgical history and no history of hiatal hernia, though the patient was taking alendronate (known to cause gastric ulcers) and did suffer from known peptic
0899-7071/$ – see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.clinimag.2014.02.005
Please cite this article as: Reicher JJ, Mindelzun R, Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.02.005
2
J.J. Reicher, R. Mindelzun / Clinical Imaging xxx (2014) xxx–xxx
pericardial fistula [5]. The clinical presentation of gastropericardial fistula is variable and can include chest pain, fever, and tachycardia as in the subject of this case report, but also dyspnea, dysphagia, and cardiac tamponade [5]. The initial differentiating feature for these otherwise nonspecific symptoms is typically a chest radiograph, which readily demonstrates air within the pericardial space, visualized as sharp outlining of the pericardium by air on both sides. Pneumopericardium is radiographically distinguished from pneumomediastinum by its superior limit at the pericardial reflection at the root of the aorta and main pulmonary artery. Spontaneous atraumatic pneumopericardium on a chest radiograph is an uncommon finding but should stimulate investigation for an underlying etiology. In particular, in patients with risk factors for entero-pericardial fistula including prior esophageal surgery, prior diaphragmatic hernia repair, significant ulcer disease, or gastrointestinal malignancy, suspicion for a finding of an underlying fistula should be high. Contrast-enhanced CT scan is useful and may demonstrate disruption of normal tissue planes, a suspected fistula track, and dissecting air [3]. Others recommend an upper gastrointestinal (GI) tract series with water-soluble contrast for initial evaluation in stable patients [5]. While endoscopy can assist in diagnosis, some recommend avoiding endoscopy if possible given the potential risk for inducing or worsening cardiac tamponade with the introduction of additional air into the stomach [6]. For treatment, though a few cases of successful conservative management have been reported, a more common consensus recommends early diagnosis and surgical management when possible [7,8]. Because mortality rates have been reported to be as high as 85%, early detection followed by timely surgery is generally recommended [8]. 3. Ethical standards No experimental research was performed in the development of this manuscript. Acknowledgments Fig. 1. Two-view chest X-ray with anteroposterior (AP) and lateral views demonstrating a large pneumopericardium.
None. References
ulcer disease for which she was receiving treatment [3]. Thus, the case described herein is somewhat unique in that this 53-year-old patient had no known history of hernia, no prior surgeries, and no history of ulcer disease, except for the single ulcer discovered on the ensuing EGD that otherwise revealed mild gastritis and no additional ulcers. Interestingly, the location of the ulcer is notably similar to that of the case reported in 1998. Historically, cases of perforated gastric fundus ulcers leading to subphrenic abscesses that subsequently dissected through the diaphragm and into the pericardium have been reported, though the time course is typically subacute rather than acute [4]. Patients with gastropericardial fistula have typically been treated surgically with a high mortality, though case reports of survival nonoperatively have been published [1,3]. Pneumopericardium itself is relatively uncommon, though it can be apparent after cardiac surgery or as a complication of trauma, esophageal ulceration, or a variety of other causes, including entero-
[1] Imran Hamid U, Booth K, McManus K. Is the way to a man's heart through his stomach? Enteropericardial fistula: case series and literature review. Dis Esophagus Jul 2013;26(5):457–64. http://dx.doi.org/10.1111/j.1442-2050.2012.01373.x. [2] Park S, Kim JH, Lee YC, Chung JB. Gastropericardial fistula as a complication in a refractory gastric ulcer after esophagogastrostomy with gastric pull-up. Yonsei Med J March 1 2010;51(2):270–2. [3] Chapman PR, Boals JR. Pneumopericardium caused by giant gastric ulcer. AJR Am J Roentgenol Dec 1998;171(6):1669–70. [4] Reisberg IR. Endoscopic antemortem diagnosis of gastropericardial fistula caused by perforation of benign gastric ulcer. Gastrointest Endosc Aug 1974;21(1):27–9. [5] Simice P, Zwirewich CV. Gastropericardial fistula complicating benign gastric ulcer: case report. Can Assoc Radiol J Aug 2000;51(4):244–7. [6] Ruano Poblador A, Gay Fernández AM, García Martínez MT, et al. Pneumopericardium caused by gastropericardial fistula. Rev Esp Enferm Dig Mar 2007;99(3): 168–71. [7] Grandhi TM, Rawlings D, Morran CG. Gastropericardial fistula: a case report and review of the literature. Emerg Med J 2004;21:644–5. http://dx.doi.org/10.1136/ emj.2003.007765. [8] Letoquart JP, Fasquel JL, L'Huillier JP, Babatasi G, et al. Gastropericardial fistula. Review of the literature apropos of an original case. J Chir (Paris) Jan 1990;127(1): 6–12.
Please cite this article as: Reicher JJ, Mindelzun R, Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.02.005
J.J. Reicher, R. Mindelzun / Clinical Imaging xxx (2014) xxx–xxx
3
Fig. 2. Contrast-enhanced CT of the chest and abdomen. (A) Redemonstration of a large pneumopericardium; (B), (C), (D), (E) Subtle loss of a distinct tissue plane (arrow) between the cardia of the stomach, the diaphragm, and the inferior aspect of the pericardium, with apparent tracking of air in this region. On the lesser curvature of the gastric fundus, note the deep ulcer with heaped-up symmetrical mucosa and an ectopic gas collection in its center, compatible with benign ulceration. (F), (G) Demonstration of the same findings (arrow) in coronal (F) and sagittal (G) reconstructions.
Please cite this article as: Reicher JJ, Mindelzun R, Case report: benign gastric ulcer erosion leading to a gastropericardial fistula in a patient with no known risk factors, Clin Imaging (2014), http://dx.doi.org/10.1016/j.clinimag.2014.02.005