Gastropericardial fistula: a case report

Introduction

Gastric and duodenal perforations are the most serious complications of ulcers and neoplasms of these organs. The majority of perforations penetrate to the peritoneal cavity. Sometimes the stomach cardia and fundus ulceration do not adhere to the peritoneum and can penetrate proximally to the pericardium creating gastro-pericardial fistula (GPF) [1, 2,
4-6]. We have not found such a case in the Polish medical literature, so we considered it desirable to describe the case.

Case report

A 60-year-old patient was admitted to our hospital, complaining of chest pain lasting 7 hours, clinical and laboratory signs of sepsis. He denied vomiting or gastric ulcers. The chest X-ray revealed pneumopericardium, water soluble-contrast study of the esophagus showed gastric cardia and fundus infiltration. The chest CT detected air and contrast in the pericardium. The gastroscopy confirmed infiltration of the gastric cardia and fundus with centrally located fistula (Fig. 1-4). Emergency surgery was conducted. Intraoperatively the vast infiltration of cardia, fundus, celiac trunk, spleen hilum, diaphragmatic hiatus and pericardium were observed. Under these circumstances and due to no possibility of intraoperative pathological examination, we decided to perform splenectomy and Ivor-Lewis cardia resection completed by diaphragmatic and pericardial infiltration resection. The additional lymphadenectomy of the celiac trunk, gastric curvatures and posterior mediastinum was performed. We established the diagnosis of pericardial empyema and the bacterial smear revealed Escherichia Coli and Candida Albicans cultures demanding Fluconazole and Ceftazidime therapy. After intensive Betadine (Iodine solution) lavage of the pericardium we reconstructed the pericardial sac with remaining pericardial fenestration to the right pleural cavity. The patient was discharged home taking chemoprophylaxis and vaccination against capsular bacteria.

Discussion

This was the first such a case operated at our institution. The intense symptoms of chest pain, fever and laboratory inflammation markers were fully reflected in the gastroscopic and radiologic findings (chest X-ray, contrast study, computed tomography). The fistula between gastric fundus and pericardium had a broad lumen and prevented heart tamponade, which occurs in 37% of described cases [2]. Intraoperative “adhesion” penetration criteria of the infiltration process including surrounding anatomical structures were met and the “technical” splenectomy enabled conducting successful surgery as previously described [1, 6].
The range of the operation complied with potential oncologic margins and the gastro-intestinal tract reconstruction was performed within the parts free of the infiltration. The bacteriologic findings were similar to the other authors’ reports and the postoperative course was uneventful [2]. The GPF case ought to undergo surgery because of high mortality rate if treated conservatively, though single patients were successfully cured in such way [1, 3, 5]. The chest pain coexisting with pneumopericardium are the first and major signs of the fistula. The other symptoms are not so frequent and they consist of arrhythmias, gastric bleeding, peritoneal manifestation with radiation to the supraclavicular region or tamponade [1, 2, 4]. The gastroscopy should be conducted with the highest care due to possible exacerbation of tamponade symptoms caused by the valve mechanism in the fistula orifice [1, 2]. Some GPF can occur due to gastric dislocation following esophagectomy, fundoplication or in the course of subphrenic abscess and untreated esophageal hiatal hernia. The pericardial empyema symptoms are nevertheless similar in these patients [2, 5, 7, 8]. The differential diagnosis should include esophageal-pericardial fistula and Boerhave syndrome [7, 9, 10]. The extreme and always lethal GPF form is gastro-cardiac fistula, which fortunately is rare [6].

References

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