CASE REPORT Gastropericardial fistula complicating an adenocarcinoma of the stomach IntroductionAS Shaik MBC/18 (Natal), FCS (SA) Of the various conditions affecting the stomach, gastric cancer invariably imparts a fatal outcome, death being usually due to the indolent yet relent- less malignant process. Rarely a com- plication such as a gastropericardial fis- tula may be the cause of the fatal event. Gastropericardial fistula with the re- sultant pneumopericardium is an ex- tremely rare condition with a high mor- tality.l,2,3This condition was first de- scribed by Hallin in 1891.4 To date 57 cases of gastropericardial fistula due to a disparate group of conditions have been reported in the literature.',s,6,7,8,9 Amongst the causes described are thoraco-abdominal trauma.v" systemic infections, previous gastro-oesophageal surgery': 10,II adjacent inflammatory foci and benign gastric ulcers. I,3,12Of the re- ported cases, 10 have been attributed to underlying gastric malignancy. I In this report we present a fatal case of gastropericardial fistula arising from the transdiaphragmatic invasion of a ma- lignant gastric ulcer. B Singh FCS(SAT J Maharajh FFRad (SAY J Moodley FCS (SA) Department of General Surgery and' Radiology, University of Natal Medical School, Durban, South Africa Case report A 36-year-old man presented to the Medical Service at King Edward VIII 15 SA JOURNAL OF RADIOLOGY· May 1998 Hospital in Durban with a one month history of loss of appetite and weight, progressive breathlessness, swelling of the legs and dysphagia. On presenta- tion he was found to be emaciated with a tinge of jaundice, left supraclavicular lymphadenopathy, pitting oedema of the lower limbs and in congestive car- diac failure. Chest examination re- vealed fine crackles along both lung bases; auscultation of the heart revealed a pericardial friction rub. Abdominal examination revealed no abnormalities. An admission chest x-ray revealed features of cardiac failure and the pa- tient was initially managed for a peri- carditis and cardiac failure. The haemo- globin was 10.2 g/dl and white cell count was 12.4 x 109. The urea and electrolytes revealed a mildly elevated serum urea. ECG changes were in keeping with cardiac failure and a peri- carditis. Over the ensuing two days no improvement was noted in the pati nt's general condition and the dysphagia persisted. A barium swallow performed showed a normal oesophagus. However a fistula between the lesser curve of the stomach and the pericardial cavity was easily demonstrated (Figure 1). De- layed radiographs depicted a large pneumopericardium (Figure 2). The ra- diological features of the stomach sug- gested a malignant process. Subse- quently at gastroscopy, a shrunken stomach with a malignant appearing ulcer along the lesser curve of the stom- ach was noted and biopsied. The fis- tula was not identified. Shortly after the gastroscopy the patient's condition rap- idly deteriorated and he demised with- out any definitive treatment. Histologi- cal assessment of the gastroscopic bi- opsy revealed an adenocarcinoma of the stomach. to page 18 GE MACMED A NEW GIANT EMERGES IN THE MEDICAL EQUIPMENT SERVICING MARKET A new giant has emerged in South Africa's R300 million p,a. medical equipment servicing market with the launch of a GE Macmed Joint venture targeting a R70 million turnover In Its first year by breaking with tradition to launch servicing of competing brands of healthcare equipment. "General Electric (GE) took a strategic decision to launch multi- vendor servicing of medical equipment South Africa in partnership with a well established local company," says Christopher Austin, GE Medical Systems General Sales Manager for southern Africa. 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V E GEMacmed Tel (011) 315-6625 Gastropericardial fistula con'lplicating an adenocarcinoma of the stomach from page 15 Figure 1: Gastroperlcardial fistula (arrow) with barium outlining the pericardlal sac. Figure 2: Chest radiograph demonstrating pneumopericardium. Discussion Whilst the complications of malig- nant gastric ulcers are usually predict- able, only awareness of the rare and invariably fatal gastropericardial fistula occurring as a result of this condition will result in its early recognition and treatment. The anatomical proximity of the lesser curve of the stomach to the pericardium readily predisposes to fistulation between these two struc- tures. However, because of the strength of the fibrous central tendon, such fistulation is rare. In our patient it could be postulated that adhesion of the lesser curve of the stomach to the diaphragm with subsequent trans-serosal extension of the tumour and invasion of the cen- tral tendon gave rise to the fistula. The patient probably presented just prior to complete fistulation which would explain the absence of a pneumoperi- cardium on the admission chest x-ray. It may be speculated that the gastros- copy actually exaggerated the pneu- mopericardium and hastened the pa- tient's demise. Chest pain, dyspnoea, cyanosis and shock with a pericardial friction rub or occasionally loud bruit or bruit de moulin are the cardinal symptoms and signs of pericarditis associated wi th a gastropericardial fistula. 3,I 0 Occasionally these patients present with cardiac tamponade'" as a result of the pneumopericardium which maybe complicated by an empyaema if the diagnosis is delayed.v'"!' In the presence of a pneumopericardium, a chest x-ray is usually diagnostic. How- ever a contrast study is indicated to identify the site of the fistula and sometimes as in our patient, to assist with the pathological diagnosis. Gossof identified three features common to gastropericardial fistulae irrespective of the underlying causes previously mentioned: • Frequency of hiatus hernia in the genesis of these lesions;2J,g,13either from an ulcer, oesophagitis or herniated stomach or from surgical complications • Need for aggressive treatment • High mortality - 68% Regardless of the aetiology, the re- ported mortality from this condition ranges between 68 and 85%.1,2These extremely ill patients should be 18 SA JOURNAL OF RADIOLOGY· May 1998 aggressively resuscitated, admitted to an intensive care unit, given inotropic sup- port and antibiotics and ventilatory sup- port should be considered.' Once the diagnosis has been confirmed, surgical intervention should take place as soon as possible. Letoquart' reviewed 52 cases and found that 42 were related to benign conditions. The overall mortal- ity was 85%, although one in two pa- tients survived if urgent surgery was re- sorted to. The prognosis in this condi- tion may be enhanced with aggressive resuscitation, pericardial drainage and appropriate gastro-intestinal surgery.I ,2,3,lO Although the risks associated with sur- gery in these patients are extremely high, they are less likely to result in mortality which is almost invariable in the con- servatively managed patient. References I. LetoquartJP, Fasquel JL, L'Huillier JP, Babatast G, Gruel Y, Lauvin R, Mambrini A. Les fistules gastro- pericardiques. Revue de la litterature a propos d'un cas original. 1 de Chir 1990; 127 (1): 6-12. 2. Gosser D, Mariambourg G, Assens P, Sarfan E, Celerier M, Dubast C. Fistule gastro-pericardique. Complication tardive d'une cure de hernie hiatale. 1 de Chir 1986; 123 (12) 704-8. 3. Nicolaou N, Katz G, Conlan AA. Gastropericardial fistula presenting as acute cardiac tamponade. S Afr Med 1 1984; 65 (2): 51-2 4. Hallin, cited by Pick L. Z Klill Med 1891; 26: 452. 5. Edwards JR, Humeniuk V. Castropericardlal Fistula. Austr and New ZealJ Surg 1996; 66 (4): 257-9. 6. Schneider F, Schenk M, TempeJD, Thiry L. Spontaneous gastropericardial fistula. AIIII Emerg Med 1995; 26 (3): 394. 7. Prabhudev N, Ramesh B, Prabhakar, Rao AS. "Gastropericardial fistula" presenting as cardiac tamponade. } Assoc Pltys India 1994; 42 (2): 157-8. 8. SaloJA, Heikkila L, Nemlander A, Lindahl H, Louhirno I, Mattila S. Barrett's oesophagus and perforation of gastric tube ulceration into the pericardium : a late complication after reconstruction of oesophageal atresia. AliI! Chir e: Gynae 1995; 84 (1): 92-4. 9. Mukai M, Nimomiya T, Ocji N, Hamada M. An 80 year old female with pneumopericardium due to gastric perforation. Nippon Rom", Igakkai Zassilli - lap} Geriatr 1995; 32 (2): 123-7. 10. GIeser RA. A case of gastroperieardial fistula. S Afr Med J1973; 39: 1799-801 Il. Ikard RW, Jacobs JK. Gastropericardial fistula and pericardtal abscess: unusual complications of subphrenic abscess following Nissen fundoplication. South MedJ 1974; 67 (I): 17-9. 12. Ghahremani GG, Yaghmai S, Brooks lW, Hutton CF. Pneumopericardium due to transdiaphragmatic perforation of a gastric ulcer. Am } Digest Dis 1976; 21 (7): 586-91 13. MonrolL, Nicholls Rl, HatelyW, Murray RS, Flavell G. Gastropericardial fistula - a complication of hiatus hernia. Brit} Surg 1974; 61 (6): 445-7.