Abstract
Background
A 64-year-old woman presented to the emergency department with pneumopericardium two weeks post-pericardial window with imaging revealing parietopericardal hernia containing small bowel.
Summary
Parietopericardial herniation is described as the herniation of abdominal contents through a diaphragm defect into the pericardial space and is seen after various surgical and non-surgical etiologies. We present a patient post pericardial window with small bowel strangulation due to parietopericardial herniation.
Conclusion
The differential diagnosis for pneumopericardium post-cardiothoracic surgical procedures should include parietopericardial hernia to identify herniation earlier and involve appropriate surgical consultation.
Key Words
diaphragm; hernia; parietopericardial hernia; pneumopericardium
Case Description
Parietopericardial herniation occurs via disruption in the structural integrity of the diaphragm via various methods, including congenital malformations, trauma, or postoperatively. This weak point in the diaphragm may lead to herniation of abdominal contents into the chest causing tamponade physiology and possible organ strangulation or ischemia. We present a case of a 64-year-old woman with metastatic breast cancer who had a pericardial window with subsequent parietopericardial herniation and small bowel strangulation.
The patient presented as a transfer to our hospital due to worsening clinical condition with findings of pneumopericardium and complaints of dyspnea. Upon initial presentation to the outlying hospital, she did not have obstructive symptoms or abdominal pain. She presented to our emergency department with acute onset generalized abdominal pain that radiated to her back with associated dizziness, weakness, and vomiting. She had a past medical history significant for metastatic breast cancer treated with radiation and chemotherapy. Two weeks prior to this presentation, she underwent a subxiphoid pericardial window at another hospital for a malignant pericardial effusion with tamponade physiology and was subsequently discharged home. Her other notable medical history was relevant for malnutrition, chronic obstructive pulmonary disease, type II diabetes mellitus, and a 44 pack/year smoking history.
CT imaging was done at an outlying hospital with intravenous but without oral contrast of the chest, abdomen, and pelvis. Imaging revealed pneumopericardium; however, a diagnosis of the parietopericardial herniation was not made. The decision was made to transfer this patient to our tertiary care center for further evaluation and treatment.
Upon arrival, the patient had diffuse abdominal pain and obstructive symptoms. Vital signs were temperature of 95.9°F, sinus tachycardia with a rate of 124 beats per minute, blood pressure 88/60mmHg, respiratory rate of 30, and 97% SaO2 on 4L nasal cannula. Given her change in exam, repeat imaging was obtained to assess for abdominal pathology. Repeat imaging revealed parietopericardial herniation, which contained small bowel (Figure 1 to Figure 3). A small number of ascites was noted on CT. Broad-spectrum antibiotics and fluid resuscitation were initiated, and acute care surgery was consulted. Her lab work was notable for worsening leukocytosis, liver function tests concerning for shock liver, acute kidney injury, and elevated INR (Figure 1).
Figure 1. Coronal CT Image Herniation of Small Bowel Herniation into Pericardial Space. Published with Permission
Arrow pointing to pericardial and small bowel interface.
Figure 2. Sagittal CT Image of Small Bowel Herniation into Pericardial Space. Published with Permission
Arrows showing diaphragm defect with small bowel entering pericardial space.
Figure 3. Axial Image Showing Small Bowel in Pericardial Space with Air-Fluid Level. Published with Permission
