Eur J Cardiothorac Surg 2001;20:1267-1269
© 2001 Elsevier Science NL
Delayed diagnosis of purulent pericarditis caused by esophagopericardial fistula by computed tomography scan and echocardiography
Jong Bum Choi,
Sam Youn Lee,
Jin Won Jeong
Departments of Thoracic and Cardiovascular Surgery and Cardiology, Wonkwang University Hospital, Iksan, South Korea
Received 11 July 2001;
received in revised form 24 September 2001;
accepted 27 September 2001.
Corresponding author. Tel.: +82-63-8501275; fax: +82-63-8570252
e-mail: jobchoi{at}wonnms.wonkwang.ac.kr
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Abstract
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We report a case of esophagopericardial fistula with subsequent purulent pericarditis that was diagnosed with computed tomography and echocardiography. In a patient with non-specific chest pain and vague past history, serial echocardiography demonstrated rapid aggravation of pyopneumopericardium and chest CT scan showed a foreign body that caused the fistula in the esophageal wall. Removal of a piece of fish bone, closure of the fistula, and creation of a pericardial window for continuous drainage were performed through a low lateral thoracotomy.
Key Words: Esophago-pericardial fistula • Suppurative pericarditis • Foreign body • Fish bone
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1. Introduction
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The ingested foreign body may rarely make perforation of the lower esophagus and cause an esophagopericardial fistula followed by purulent pericarditis [1]. Most of the fistula is an acute illness associated with characteristic clinical finding and extremely high mortality [1,2]. Early recognition and prompt management of the lesion is keystone to improve the clinical course. In a patient who had vague past history and non-specific chest pain, a diagnosis of purulent pericarditis following esophagopericardial fistula was made by serial echocardiography and computed tomography scanning and a successful surgical management was performed before the fatal complication occurs.
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2. Case report
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A 41-year-old man was admitted with retrosternal pain and right anterior chest tightness for 2 days before admission. The symptom was more severe at inspiration and relieved in squatting position. At admission, chest X-ray film was normal. On the 1st hospital day, the body temperature was elevated to 37.5°C, and the pulse rate increased to 110 beats per minute. In the laboratory study, hemoglobin was 12.7 g/dl, white blood cell 15.7x103/ml, creatinine kinase 983 U/l, creatinine kinase-MB 10 U/l, and LDH 689 U/l. Electrocardiography revealed ST-segment elevation in all precordial leads, which suggested acute pericarditis. There was no abnormal finding on the first echocardiography, but serial echocardiography for the next 3 days showed progressive increase of free echo space and spontaneous echo contrast suggestive of air collection in pericardial cavity (Fig. 1)
. On the third hospital day, the chest X-ray film displayed enlarged cardiac shadow and hydropneumopericardium, but on echocardiogram amount of the pericardial fluid was not enough for pericardiocentesis. Chest CT scan showed a white thread density in the left lateral wall of the lower esophagus (Fig. 2)
. With a past history of eating roasted fish 3 days before admission, we suspected purulent pericarditis secondary to esophagopericardial fistula caused by fish bone. Intravenous administration of imipenam of 2.0 g per day and metronidazole of 1.5 g per day was begun. On the fourth hospital day, flexible fiber-optic esophagoscopy demonstrated only a deep white ulcer of 1-cm diameter 38 cm distal to incisor teeth. On the 5th hospital day, jugular venous pulse was elevated to 5 cm above sternal angle and operation was performed. A low left lateral thoracotomy was used to enter the pleural cavity through the 7th intercostal space. A pericardial incision was made parallel and anterior to phrenic nerve and about 200 ml of dark reddish turbid fluid was aspirated. A piece of fish bone 2-cm long that was stuck in the posterior pericardium and protruded into the pericardial cavity was removed. After loculated undrained pockets and debris were evacuated, a pericardial window of 7-cm diameter for continuous drainage was created. The esophagus was then dissected away from the posterior surface of the pericardium, and the 5-mm esophageal opening of the fistula was transversely closed using interrupted 4-0 Prolene sutures with subsequent reinforcement of in situ pleural patch. After the thoracotomy wound was closed, feeding jejunostomy and drainage gastrostomy were performed. The pericardial fluid presented protein of 5.0 g/dl, LDH of 5449 U/l, glucose of 63 mg/dl, and amylase of 589 U/l, and Escherichia coli was proved. On the postoperative 5 day, metronidazole was discontinued and intravenous administration of amikacin sulfate of 750 mg per day was begun. The antibiotics were continued until the postoperative 16-day. The postoperative course was uncomplicated, and oral feeding was begun on the postoperative 12th day. The patient is asymptomatic 19 months postoperatively.
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Fig. 1. Preoperative subcostal four-chamber view of echocardiogram shows spontaneous echo contrast in the echo-free space anterior to the right ventricle, which suggests hydropneumopericardium. EC, echo contrast; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
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Fig. 2. Computed tomographic scan demonstrates a thin foreign body (white arrow) in the esophageal wall.
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3. Discussion
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Formation of a fistula from the lower esophagus to the pericardial cavity caused by the ingested foreign body is extremely rare [3]. The clinical picture of the esophagopericardial fistula is pyopneumopericardium, and the clinical signs are similar to those of purulent pericarditis. As the esophagopericardial fistula is invariably fatal with usually complicated cardiac tamponade, early diagnosis and prompt therapy are very important [1,2,4]. A number of diagnostic procedures can be employed. Chest X-ray film displays an air-fluid level in the pericardial cavity, but it is not a specific finding of the fistula. If the history of ingesting the foreign body is presented, flexible fiber-optic esophagoscopy may be the most useful diagnostic procedure to early confirm cause of the lesion. Esophagoscopy may demonstrate the foreign body as well as an ulcerated and excavated mucosal lesion, which is an entrance of the fistula. Esophagography using contrast material may not demonstrate the small fistula. Because our case did not present the distinct past history of ingesting fish bone or the specific symptom like swallowing pain or dysphagia, we did not suggest the esophageal injury at admission and did not earlier perform fiber-optic esophagoscopy that could confirm the lesion. Esophagoscopy was performed for the first time after the pericarditis was demonstrated with echocardiography and the foreign body was presented on CT scan. The first echocardiography at admission did not show abnormal finding, but the next 3-day serial study demonstrated progression of the purulent pericarditis before cardiac tamponade occurred. The fish bone in the esophageal wall was not shown through flexible fiber-optic esophagoscope or on chest x-ray films, but readily on CT scan. A case of chronic purulent pericarditis caused by the esophagopericardial fistula was managed by removal of a fish bone and pericardiectomy through median sternotomy without closing the fistula [5]. Our case in acute stage, however, was successfully managed by removal of the fish bone in the fistula, closure of the esophageal fistula, and creation of a large pericardial window for continuous drainage through a low lateral thoracotomy.
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References
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Abstract
1. Introduction
