PMC4861863_01
Chest X-ray obtained at outside hospital shows pneumopericardium (white arrows). Heart size is normal. No pneumothorax is present.
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Initial workup for myocardial infarction was negative, but an outside-hospital chest radiograph (Fig. 1) and computed tomography (CT) of the chest revealed a large pneumopericardium.
Water-soluble swallow study shows a small outpouching from the fundus of the stomach projecting over the area of the pericardium (white arrow), which is suspicious for gastric fundal ulcer perforation into the pericardial sac and forming a gastropericardial fistula. This persistent finding is seen on multiple images and different patient positions during the study.
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An X-ray water-soluble swallow study revealed an outpouching of the gastric fundus overlying the air-filled pericardium (Fig. 2).
CT of the chest immediately after water-soluble swallow study (coronal view). The collection of contrast (white arrow) corresponds with the small gastric outpouching seen in prior upper GI images. This is suspicious for gastric fundal ulcer perforation into the pericardial sac and formation of a gastropericardial fistula.
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A followup CT of the chest without contrast confirmed a large pneumopericardium with focal outpouching of contrast and air extending from the superior aspect of the gastric fundus through the left hemidiaphragm and abutting the surface of the posterioinferior pericardium (Figure 3, Figure 4).
CT of the chest immediately after water-soluble swallow study showing postoperative changes of Nissen fundoplication. Oral contrast is noted in the distal esophagus/stomach. There is a focal outpouching of contrast and air extending from the superior aspect of the gastric fundus that extends through the left hemidiaphragm and abuts the surface of the posteroinferior pericardium (white arrow). Findings are of large pneumopericardium (white arrowheads) with indications of a gastropericardial fistula, as described above.
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A followup CT of the chest without contrast confirmed a large pneumopericardium with focal outpouching of contrast and air extending from the superior aspect of the gastric fundus through the left hemidiaphragm and abutting the surface of the posterioinferior pericardium (Figure 3, Figure 4).
Focal collection of contrast (white arrow) in the dependent portion of the pericardial sac. The patient is in the prone position. This is consistent with contrast entry into the pericardial sac from prior recent upper GI studies, confirming the presence of a gastropericardial fistula.
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In addition, there was a small focus of hyperdensity in the dependent portion of the pericardial sac, suggestive of extravasated enteric contrast from the recent water-soluble swallow study, and a gastropericardial fistula (Fig. 5).
Visualization of gastropericardial fistula in fundus of stomach via endoscope.
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The right ventricle could be visualized through the gastric fundus (Fig. 6).