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PERITONEOPERICARDIAL FISTULA: A RARE CASE OF PERSISTENT PERICARDIAL EFFUSION
1028 JACC April 5, 2016 Volume 67, Issue 13
FIT Clinical Decision Making PERITONEOPERICARDIAL FISTULA: A RARE CASE OF PERSISTENT PERICARDIAL EFFUSION Moderated Poster Contributions Pulmonary Hypertension and FIT Clinical Decision Making Moderated Poster Theater, Poster Area, South Hall A1 Sunday, April 03, 2016, 12:45 p.m.-12:55 p.m. Session Title: FIT Clinical Decision Making: Moderated Poster Session IV Abstract Category: Heart Failure and Cardiomyopathies Presentation Number: 1211M-03 Authors: Carolina Ponce Orellana, Melissa LeBlanc, Elizabeth Snyder, Stacey Clegg, University of New Mexico, Albuquerque, NM, USA
Background: Peritoneopericardial fistula (PPF) is rare and usually acquired as a complication of trauma or surgery. In patients with ascites, PPF can allow the development of pericardial effusion(PE) potentially leading to cardiac tamponade. Case: 41-year-old man with hepatitis C, alcohol abuse and remote history of upper abdominal stab wound with exploratory laparotomy presented with two months of abdominal and lower extremity swelling. He was dyspneic, tachycardic and hypotensive. Physical exam revealed distant heart sounds, jugular venous distention and swollen abdomen with fluid wave. Laboratories were remarkable for thrombocytopenia, hypoalbuminemia, coagulopathy and imaging confirmed a diagnosis of cirrhosis. Chest x-ray showed an enlarged cardiac silhouette and echocardiogram confirmed a large PE with tamponade physiology. He underwent emergent pericardiocentesis with drain placement. An initial 1.5 liters of fluid was removed, and over the following 3 days, 9 liters of fluid continuously drained.
Decision Making: Laboratory studies ruled out infectious, rheumatologic or malignant causes of PE. With removal of the pericardial drain, fluid rapidly reaccumulated in the pericardial space. Paracentesis was done and pericardial and peritoneal fluid analysis were essentially identical. Ascitic fluid analysis revealed SAAG (Serum Ascites Albumin Gradient) >1.1 consistent with portal hypertension. Given the history of upper abdominal stab wound and the similarity between the pericardial and peritoneal fluid, presence of a PPF was suspected. Nuclear medicine-single photon emission computed tomography with macroagregated albumin (SPECT MAA) confirmed PPF. Diuretics were not effective and patient was a poor surgical candidate for fistula repair. He underwent Transjugular intrahepatic portosystemic shunt (TIPS) procedure resulting in resolution of ascites and PE. Conclusions: This case presents an interesting etiology of PE caused by PPF from a prior upper abdominal stab wound in the setting of cirrhosis with ascites. The tract was elucidated with SPECT with MAA which was ordered due to clinical suspicion of fistula. TIPS proved to be an effective treatment.
FIT Clinical Decision Making PERITONEOPERICARDIAL FISTULA: A RARE CASE OF PERSISTENT PERICARDIAL EFFUSION Moderated Poster Contributions Pulmonary Hypertension and FIT Clinical Decision Making Moderated Poster Theater, Poster Area, South Hall A1 Sunday, April 03, 2016, 12:45 p.m.-12:55 p.m. Session Title: FIT Clinical Decision Making: Moderated Poster Session IV Abstract Category: Heart Failure and Cardiomyopathies Presentation Number: 1211M-03 Authors: Carolina Ponce Orellana, Melissa LeBlanc, Elizabeth Snyder, Stacey Clegg, University of New Mexico, Albuquerque, NM, USA
Background: Peritoneopericardial fistula (PPF) is rare and usually acquired as a complication of trauma or surgery. In patients with ascites, PPF can allow the development of pericardial effusion(PE) potentially leading to cardiac tamponade. Case: 41-year-old man with hepatitis C, alcohol abuse and remote history of upper abdominal stab wound with exploratory laparotomy presented with two months of abdominal and lower extremity swelling. He was dyspneic, tachycardic and hypotensive. Physical exam revealed distant heart sounds, jugular venous distention and swollen abdomen with fluid wave. Laboratories were remarkable for thrombocytopenia, hypoalbuminemia, coagulopathy and imaging confirmed a diagnosis of cirrhosis. Chest x-ray showed an enlarged cardiac silhouette and echocardiogram confirmed a large PE with tamponade physiology. He underwent emergent pericardiocentesis with drain placement. An initial 1.5 liters of fluid was removed, and over the following 3 days, 9 liters of fluid continuously drained.
Decision Making: Laboratory studies ruled out infectious, rheumatologic or malignant causes of PE. With removal of the pericardial drain, fluid rapidly reaccumulated in the pericardial space. Paracentesis was done and pericardial and peritoneal fluid analysis were essentially identical. Ascitic fluid analysis revealed SAAG (Serum Ascites Albumin Gradient) >1.1 consistent with portal hypertension. Given the history of upper abdominal stab wound and the similarity between the pericardial and peritoneal fluid, presence of a PPF was suspected. Nuclear medicine-single photon emission computed tomography with macroagregated albumin (SPECT MAA) confirmed PPF. Diuretics were not effective and patient was a poor surgical candidate for fistula repair. He underwent Transjugular intrahepatic portosystemic shunt (TIPS) procedure resulting in resolution of ascites and PE. Conclusions: This case presents an interesting etiology of PE caused by PPF from a prior upper abdominal stab wound in the setting of cirrhosis with ascites. The tract was elucidated with SPECT with MAA which was ordered due to clinical suspicion of fistula. TIPS proved to be an effective treatment.