Gastropericardial fistula: radiologic findings and literature review

Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities

Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.

A difficult-to-diagnose pericardial fistula

Pericardial fistula is a rare complication. Generally, the diagnosis can be confirmed by imaging examination, but our patient was an exception. We present a 71-year-old female patient that complained of remnant gastric cancer for five months and dyspnea for seven days; the dyspnea became aggravated during the last two days. After admission, emergency thoracic computed tomography and echocardiography showed pericardial effusion, and pericardiocentesis was performed. After conventional treatment, the pericardial effusion was unchanged and no cancer cells were found in the pericardial drainage. However, the color changed from turbid to golden yellow and, finally, to green. After 20 days of repeated laboratory, imaging, and gastrointestinal contrast examinations, no cause was found. Moreover, a clinical diagnosis could not be obtained following numerous comprehensive clinical analyses. Given the color change of the pericardial drainage, we strongly suspected pericardial fistula, but the imaging examinations were negative. Finally, a methylene blue test confirmed the existence of a pericardial fistula. When the color of the pericardial effusion changes, the existence of a pericardial fistula must be considered in advance, and other methods should be evaluated if imaging cannot assist in the diagnosis.

Rare atypical presentation of a polymicrobial gastropericardial fistula

We present the unique case of a gastropericardial fistula with a rare, delayed presentation in a man in his 70s. Relevant surgeries include Watchman Left Atrial Appendage Closure device placement 1 year prior to arrival and gastric bypass surgery 20 years prior to arrival. The patient presented to the emergency department with weakness, diarrhoea and left knee pain. He was admitted for cellulitis of the left lower extremity, prosthetic septic arthritis of the left knee and group G streptococcus bacteraemia. His hospital course was complicated by acute chest pain and dyspnoea. Imaging revealed pneumopericardium. Oesophagogastroduodenoscopy visualisation confirmed the diagnosis of gastropericardial fistula. The patient could not be transferred to a tertiary centre for definitive management because of the effect of the COVID-19 pandemic on tertiary hospital volumes. After pericardial drainage and administration of antimicrobials without improvement, the patient was discharged to hospice care at his request and died 1 day after discharge.

Bariatric surgery, gastrointestinal hormones, and the microbiome: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of bariatric surgery (i.e., bariatric procedures that improve metabolic disease are often termed "metabolic and bariatric surgery"), gastrointestinal hormones, and the microbiome as they relate to patients with obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS includes the pros and cons of the most common types of bariatric procedures; the roles of gastrointestinal (GI) hormones in regulating hunger, digestion, and postabsorptive nutrient metabolism; and the microbiome's function and relationship with body weight. This CPS also describes patient screening for bariatric surgery, patient care after bariatric surgery, and treatment of potential nutrient deficiencies before and after bariatric surgery. Finally, this CPS explores the interactions between bariatric surgery, GI hormones, and the microbiome.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding bariatric surgery, gastrointestinal hormones, and the microbiome is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Implementation of appropriate care before and after bariatric surgery, as well as an awareness of GI hormones and the microbiome, may improve the health of patients with obesity, especially patients with adverse fat mass and adiposopathic metabolic consequences.

Chest Pain from Pneumopericardium with Gastropericardial Fistula

Introduction

Gastropericardial fistula, a connection between the upper gastrointestinal tract and pericardium, is a rare clinical finding most commonly associated with postsurgical complications, as well as direct tissue invasion from gastric cancer. Case Report. We report a case of a 58-year-old Caucasian woman with metastatic colon cancer treated with FOLFOX, a combination chemotherapy regimen, and bevacizumab who presented with chest pain. She was ruled out for acute coronary syndrome, aortic dissection, or pulmonary embolism. A computed tomography (CT) scan of her chest showed pneumopericardium. A barium swallow ruled out esophageal ulceration, and esophagogastroduodenoscopy (EGD) showed a large penetrating gastric ulcer with no evidence of gastric dysplasia or malignancy or evidence of Helicobacter pylori (H. pylori). The patient underwent median sternotomy with gastric ulcer resection and repair, as well as pericardial washout and pericardial chest tube placement. After an uncomplicated course, she was safely discharged home.

Conclusion

Given that gastrointestinal ulceration and perforation are known phenomena in patients taking vascular endothelial growth factor (VEGF) inhibitors, surveillance endoscopy may be beneficial to discover them before they result in potentially fatal complications such as gastropericardial fistulas.

Gastropericardial fistula induced acute purulent pericarditis

Gastropericardial fistula is a rare but lethal condition. Several etiologies have been reported, including previous gastric or esophageal surgery, malignancy, trauma, infection, and ulcer perforation. Typical symptoms included chest pain, epigastric pain, fever and dyspnea. Gastropericardial fistula can lead to serious complications, including cardiac tamponade, sepsis, hemodynamic compromise and death. Therefore, early diagnosis and timely management are important for physicians to prevent from catastrophic complications. Here, we present a case of a man who presented with acute purulent pericarditis secondary to a gastropericardial fistula to highlight the pathogenesis and suggest therapeutic strategies.

Gastropericardial fistula presenting with cardiac arrest: a case report

Introduction

Gastropericardial fistulas are rare conditions, with less than 100 reported cases. The diagnosis is associated with significant morbidity, prolonged hospitalization and often has a fatal outcome.

Case presentation

We describe a unique case of cardiac arrest caused by pneumopericardium and cardiac tamponade as the acute presentation of a gastropericardial fistula, in a patient admitted with an infection of unknown origin. Rapid return of spontaneous circulation occurred, and a computed tomography scan revealed the diagnosis. A benign penetrating ulcer was found on gastroscopy, and surgical management with laparotomy and gastrorrhaphy was performed. The patient had no risk factors for gastric ulceration. However, he had significant comorbidity, which makes survival through a complicated postoperative course to full recovery remarkable.

Discussion

This case shows that pneumopericardium due to a penetrating benign gastric ulcer can cause cardiac tamponade, and illustrates the value of a multidisciplinary approach to management.

Gastropericardial fistula: A rare etiology of chest pain

Gastropericardial fistula is an abnormal communication between the stomach and the pericardium. It is a rare, life-threatening condition that has numerous etiologies. We report the case of a 53-year-old male patient, with a history of wedge resection for gastrointestinal stromal tumor, who presented to the emergency department for epigastric and chest pain along with lethargy leading to the uncommon diagnosis of gastropericardial fistula with pneumopericardium. Through this case, we would like to draw clinicians’ attention to gastropericardial fistula as a differential diagnosis in patients presenting for epigastric and/or chest pain with a history of esophagogastric surgery, emphasizing on the key role of computed tomography in this regard, and underscore the management basics of this unusual condition.

A case report of spontaneous umbilical enterocutaneous fistula resulting from an incarcerated Richter's hernia, with a brief literature review

BACKGROUND

Richter's hernia is a high-risk ischaemic gastrointestinal disorder that is typically diagnosed in a delayed manner due to a lack of obvious symptoms. Spontaneous umbilical enterocutaneous fistula (ECF) resulting from an incarcerated Richter's hernia is extremely rare.

CASE PRESENTATION

A 62-year-old female presented with a chief complaint of recurrent umbilical region infection for the preceding 20 months with no symptoms of ileus. Preoperative CT and fistulography revealed an incarcerated Richter's hernia complicated by an ECF. Exploratory laparotomy revealed a loop of the distal ileum adherent to the umbilical region that was retrieved back into the abdominal cavity. Side-to-side ileo-ileal anastomosis was performed using a 75 mm linear stapler to remove the affected ileum segment. The internal hernia ring was closed using plication sutures instead of via mesh repair due to the patient's small defect and infection risk.

CONCLUSION

Richter's hernia can be observed at any age but is particularly common in frail, elderly patients. This nonspecific clinical and laboratory findings of this condition are associated with a high misdiagnosis rate, resulting inrelatively high mortality. Abdominal CT and gastrointestinal imaging are recommended if Richter's hernia is suspected. Timely surgical intervention is crucial for reducing mortality and improving prognosis.