Esophago-Pericardial Fistula Associated with a Sharp Foreign Body Presenting with Tension Pneumopericardium and Cardiac Arrest During Endoscopy: A Case Report
This case report describes a rare instance of cardiac arrest caused by tension pneumopericardium resulting from an esophago-pericardial fistula due to a sharp foreign body, which was successfully managed through emergent pericardiocentesis, endoscopic foreign body removal, and surgical intervention.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Imagine your body as a high-tech fortress with separate rooms for different jobs. The esophagus is the "food slide" that sends dinner down to the stomach, while the pericardium is a tiny, watery balloon sac that cushions the heart, keeping it safe and slippery. Usually, these two rooms are separated by a thick, sturdy wall.
But in this wild story, that wall got a hole punched right through it.
The Intruder and the Leak
A 55-year-old farmer ate a meal and accidentally swallowed something sharp—like a tiny, jagged intruder. This sharp object didn't just sit there; it poked a hole in the food slide (the esophagus) and burrowed straight into the heart's protective balloon. This created a secret tunnel called an esophago-pericardial fistula.
Suddenly, the heart's balloon wasn't just filled with its normal lubricating fluid; it was being invaded by air and pus from the food slide. The doctors saw this on a CT scan: a tiny 6 mm puddle of fluid around the heart, and later, air bubbles where they shouldn't be. The patient had chest pain and trouble breathing, but because the symptoms were vague, the real danger was hiding in plain sight.
The Dangerous Game of Endoscopy
To find the culprit, the doctors decided to use a camera on a flexible tube (an endoscope) to look inside the throat. This is usually a safe, routine check-up. But here's the catch: to see clearly, doctors usually puff air into the tube to expand the walls, like blowing up a balloon to see the inside.
In this case, the paper suggests that puffing air into a room with a hole in it is a recipe for disaster. As the doctors gently puffed air to look around, that air rushed through the hole and flooded the heart's balloon. It wasn't just a little leak anymore; it became a tension pneumopericardium.
Think of it like a balloon being squeezed tighter and tighter until it can't expand. The air pressure built up so fast that it crushed the heart, stopping it from pumping blood. The patient's heart stopped beating right there on the table. It was a cardiac arrest caused by the very tool meant to help.
The Rescue Mission
The team had to act instantly. They performed an emergency pericardiocentesis, which is like sticking a needle into the heart's balloon to let the trapped air and about 300 mL of thick, yellow, pus-like fluid escape. Once the pressure was released, the heart started beating again.
The fluid they drained was a mess: it was cloudy, had a high level of a protein called LDH (1203 U/L), and was mostly made of infection-fighting cells (88% neutrophils). This confirmed the heart was fighting a serious battle against an infection coming from the gut.
Fixing the Hole
Once the patient was stable, the doctors went back in, but this time they were super careful. They found the sharp object lodged about 34 cm down the throat. Using special forceps, they pulled it out. Then, they used a giant, over-the-scope clip (OTSC)—imagine a heavy-duty binder clip—to clamp the hole shut.
But the job wasn't done. Because the area was so infected, the surgeons had to open the chest (a left thoracotomy) to wash out 200 mL of more pus and create a "window" in the heart's sac to let any future fluid drain out safely.
The Takeaway
Six months later, the patient was completely fine. This case teaches us a few vital lessons:
- Sharp objects are sneaky: A swallowed sharp item can create a tunnel between the food slide and the heart, which is incredibly rare but deadly.
- Air can be dangerous: If a patient has a hole in their esophagus, blowing air into it during an exam can turn a small leak into a heart-stopping emergency. The paper argues that if you must do an endoscopy in these cases, you should use minimal air or special carbon dioxide, and be ready to pop the pressure immediately.
- Teamwork saves lives: Fixing this required a gastroenterologist, a cardiologist, and a surgeon working together fast.
The authors suggest that if someone has chest pain after eating and shows air around the heart on a scan, doctors should suspect this rare tunnel immediately. Catching it early and handling the "air pressure" carefully is the only way to stop the heart from crashing.
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