Critical Care: Fellow Case Report Poster - Critical Care I |

Massive Loculated Pericardial Effusion With Tamponade Physiology Associated With Acute Pancreatitis FREE TO VIEW

Anupam Gupta, MD; Elizabeth Awerbuch, DO
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Elmhurst Hospital Center, Icahn School of Medicine at Mt Sinai, Elmhurst, NY

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

Chest. 2016;150(4_S):235A. doi:10.1016/j.chest.2016.08.248
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SESSION TITLE: Fellow Case Report Poster - Critical Care I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute pancreatitis (AP) and cardiac tamponade are associated with significant morbidity and morality. We present a case of massive loculated pericardial effusion with tamponade physiology as a complication of AP.

CASE PRESENTATION: 50 year-old man with history of alcoholic cirrhosis presented epigastric abdominal pain and seizure. Examination notable 116 beats/minute, 25 breaths/minute and diffuse abdominal tenderness. White blood cell count 12,500 cells/mcL and platelets 73 K/mcL. Lipase 1372 U/L. He was diagnosed with alcohol-associated AP. Clinical course complicated by hemorrhagic pancreatic pseudocyst formation, type 1 respiratory failure requiring intubation and acute tubular necrosis requiring dialysis. On day 46, septic shock refractory to multiple vasopressors ensued. Bedside goal-directed echocardiography revealed massive loculated pericardial effusion with tamponade physiology (Figure 1). In consultation with cardiology, pericardiocentesis was planned however patient expired prior to procedure.

DISCUSSION: Innumerable complications of AP occur due to the broad index of clinical presentation ranging from mild to life-threatening. Pericardial effusions occur uncommonly with an incidence 12-48% and morbidity up to 38%. Two risk factors for pericardial effusions are alcoholic-associated AP and pancreatic pseudocyst formation. Cardiac tamponade is rarely reported in literature, only four cases; of which, three had echocardiographic imaging revealing small-to-moderate sized effusions. This case is first to report the presence of massive circumferential loculated pericardial effusion with tamponade physiology. The pathogenesis of such effusions is not clearly elucidated. Hypotheses include fistulous communication between pancreatic bed and pericardial space, chemical pericarditis due to pancreatic enzymes entering pericardial space, and necrosis of vascular walls in areas of fat. Cardiac tamponade can occur in the presence of few to hundreds of milliliters of fluid. It is imperative to perform pericardiocentesis in patients with hemodynamic instability.

CONCLUSIONS: This is the first reported case of massive pericardial effusion with tamponade physiology due to AP. It underscores clinical utility of bedside goal-directed echocardiography. Pericardiocentesis is paramount in treatment of cardiac tamponade in hemodynamically unstable patients.

Reference #1: Veron Esquivel, D., et al. (2016). “Cardiac tamponade, an unusual complication of acute pancreatitis.” BMJ Case Rep 2016.

DISCLOSURE: The following authors have nothing to disclose: Anupam Gupta, Elizabeth Awerbuch

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