Cardiothoracic Surgery: Cardiology and Cardiothoracic Surgery |

Esophagopericardial Fistula With Pericarditis Secondary to Palliative Esophageal Stent Placement Presenting With Tamponade and Septicemia FREE TO VIEW

Abhay Vakil, MD; Saira Ajmal, MD; Alan Wright, MD; Vivek Iyer, MD
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Mayo Clinic, Jamaica, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A47. doi:10.1016/j.chest.2016.02.050
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SESSION TITLE: Cardiology and Cardiothoracic Surgery

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Esophagopericardial fistula (EPF) is a rare and potentially life threatening complication of both benign and malignant esophageal tumors. Esophageal stenting has been described as one of the potential treatment modalities. The formation of an EPF after stent placement is extremely rare and has not been well described. We report the case of a 66-year-old male with metastatic esophageal cancer who underwent palliative stent placement. Ten days later, he presented with hemodynamic instability and pleuritic chest pain. He was found to have cardiac tamponade and underwent pericardiocentesis. Imaging studies revealed an EPF.

CASE PRESENTATION: A 66-year old male diagnosed with metastatic esophageal cancer one year ago, presented with sudden-onset pleuritic chest pain. He had refused therapy for his esophageal cancer in the past and underwent palliative stenting 10 days prior. At presentation, he was found to be hypotensive (78/50 mm Hg), tachycardic (122 beats/min) and tachypneic (23/min). Electrocardiogram showed diffuse ST elevations (Fig. 1a), suggestive of pericarditis. Echocardiogram was suggestive of cardiac tamponade. Pericardiocentesis revealed frothy, turbid, foul-smelling fluid. Hemodynamics improved and patient was admitted to the critical care unit. Imaging studies showed hydropneumopericardium and bilateral pleural effusions (Fig. 1b) suggestive of an EPF. Blood cultures subsequently grew E. Coli and pericardial fluid cultures grew eikenella, streptoccus, candida and fusobacterium species. Broad spectrum antibiotics were initiated. The patient refused aggressive management and was transitioned to comfort care.

DISCUSSION: The potential of an esophageal stent to cause EPF has not been established definitively. EPF is associated with a high mortality rate that increases with delayed diagnosis. Pneumopericardium is the most common radiographic finding. Tamponade effect and mediastinitis with septicemia have been described in some cases. Prompt diagnosis followed by pericardial drainage, broad-spectrum antibiotic therapy and surgical repair are the key components of therapy.

CONCLUSIONS: It is important to recognize esophageal pathologies such as EPF as potential causes of pericardial effusion and tamponade. Early recognition of EPF followed by immediate institution of therapy is recommended, as any delay is associated with increased mortality.

Reference #1: Włodarczyk J et al. Esophago-pericardial fistula during the course of primary esophageal carcinoma. Ann Thorac Surg. 2008 Dec;86(6):1967-9.

DISCLOSURE: The following authors have nothing to disclose: Abhay Vakil, Saira Ajmal, Alan Wright, Vivek Iyer

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