Pneumopericardium

A 47-year-old homeless man presented to the emergency department 1 week after the onset of chest pain. He was hemodynamically stable. The physical examination was unremarkable. A routine complete blood count revealed 27,000 leukocytes per cubic millimeter. A chest radiograph showed pneumopericardium (arrow) without evidence of pneumothorax or pneumomediastinum. A computed tomographic scan of the chest confirmed the diagnosis of pneumopericardium and showed circumferential wall thickening of the distal esophagus with an associated esophagopericardial fistula. Esophagoscopy revealed a deep esophageal ulcer 4.5 cm in diameter, 36 cm from the incisors; the pericardial cavity and the lining of the columnar epithelium could be directly visualized to the distal 10 cm of the esophagus. Esophageal-biopsy specimens showed intestinal metaplasia with inflammation and high-grade dysplasia. The diagnosis was Barrett's esophagus. The patient was taken to the operating room, where lavage and drainage of the pericardium were performed, a pericardial patch and an esophageal stent were placed, and jejunostomy was performed. The patient's postoperative course was uneventful, and 11 months later, the patient was well.

Karoui and Bucur NEJM 359 (14): e16, Figure 1 October 2, 2008