Andrew

D. Vennos,

MD

Philip

#{149}

A. Templeton,

MD

Pneumopericardium Esophageal Carcinoma’ The authors describe a case of squamous cell carcinoma of the esophagus that was initially diagnosed as hydropneumopericardium at radiography. The patient subsequently underwent computed tomography (CT) and esophagography. CT revealed pneumopericardium, pericardial thickening, a mass in the esophagus, and bilateral effusion. Esophagography demonstrated perforation of the mid-thoracic esophagus and marked irregularity of the esophageal mucosa. To the authors’ knowledge, this is the only reported instance of esophageal carcinoma miflabby diagnosed as hydropneumopericardium. CT can be used as a primary method to investigate spontaneous pneumopenicardium. Index terms: Pneumopericardium, Radiology

1992;

Esophagus,

neoplasms,

71.321

P

Secondary

to

is a rare entity having both traumatic and nontraumatic causes. The majority of cases described are the result of blunt or penetnating chest trauma on are iatnogenic NEUMOPERICARDIUM

(ie, caused copy,

by thoracic

or positive

surgery,

pressure

The remaining causes egomy of spontaneous dium.

tion

These

with

endos-

ventilation).

fall under the catpneumopenicar-

include

penicardiab

gas-forming

bacteria

infec-

and

primary infiltrative diseases of adjacent air-containing structures. A review of

the literature

has disclosed

no other

case

of pneumopericardium many sequela of esophageal

We describe mous

cell

herein carcinoma

whom a diagnosis hydropneumopenicardium made.

as a pricarcinoma.

a patient

with

squa-

of the

esophagus

This A 55-year-old

REPORT

alcoholic

man

was

ad-

was no history of dysphagia or other symptoms of esophageal disease. A routine chest radiograph obtained at admission revealed hydropneumopenicardium (Fig i), which prompted further

radiograph

dem-

by attachments the vascular tic of

of the penicardium pedicle is virtually

pneumopenicardium

pericandial viously being

to diagnos-

(1,2).

line can vary

thickened, essentially

from

The

being

ob-

as in this patient, invisible, beading

to to

sign

2). CT revealed

(CT)

computed

(Fig 3). The esophagognam of the marked

demmid-thoirregular-

of the esophageal mucosa. The patient subsequently underwent

emergency exploratory right thoracotomy with esophagectomy, repair of an esophagopenicandial fistuba that was vi-

sualized in the subcaninal region, subtotab pericardiectomy, gastrostomy, and cervical esophagostomy. The postopera-

1992

chest

onstrated classic findings of pneumopericardium. An area of lucency surrounding the heart limited superiorly

esophagus, and bilateral pleural effusions. After performing CT, an esophagognam was immediately obtained by using diatnizoate megbumine (Hypaque 30%; Winthrop Pharmaceuticals, New

chest

(Fig

ity

RSNA,

patient’s

the appearance of a halo around the heart (1). A decrease in the size of the cardiac silhouette on successive chest

with

raphy

onstrated perforation racic esophagus and

i

thick-

tomoghydropneumopenicardium, penicardiab thickening, a mass in the region of the

evaluation

York)

From the Department of Radiology, University of Maryland Medical System, 22 S Greene St. Baltimore, MD 21201. Received June 17, 1991; revision requested July 17; revision received August 1; accepted August 5. Address reprint requests to PAT.

hydro-

pericardial

DISCUSSION

55.823

CASE

reveals

with

of asymptomatic was initially

in

182:131-132

radiograph

ening.

mitted to the hospital with a 3-day history of declining mental status. There

I

Figure 1. Chest pneumopericardium

radiographs, by

termed Minvis

correlated dium (3).

with

CT scanning

the

“small

al, has been

et

tension

provides

heart”

strongly

pneumopenicar-

an excellent

means of confirming the diagnosis of spontaneous pneumopenicardium and of determining its probable cause (4). In cases of traumatic pneumopericardium, findings at clinical examination will de-

termine the need for additional radiologic evaluation. Direct penetrating trauma

generally

agement. esophagus esophagography

If there

requires

clinical

is a possibility

man-

that

the

or bronchial tree is injured, or bronchoscopy may

be indicated.

tive course was one of progressive hemodynamic and renal deterioration, and the patient died 10 days after admission. Pathologic examination of the

Cases of spontaneous cardium resulting from the alimentary tract are

resected

any to either benign peptic ulcers or carcinoma of the stomach (5,6). Cases involving esophagopenicardial fistubas are

poorly cinoma.

esophageal differentiated

mass

revealed

squamous

cell

car-

rare.

Most

of these

appear

pneumopeniperforation exceedingly

of

to be second-

4

:,m.:4*

: Figure

2.

(a) CT

scan

mopericardium. of perforation.

even with

reveals

(b) CT scan This

may

2-cm

represent

the

more unusual but have esophagitis (7). In 1954,

Kirsh

(8) described

a man

esophageal

also reveals

mass

site

of fistuba

occurred Dassel and

with

pneumopenicardium. and

CT enabled can

method to investigate pneumopenicardium.

be used

2.

esopha-

geal carcinoma who developed pneumopericardium after undergoing expboratory thoracotomy and external beam radiation therapy. To our knowledge, our case represents the only reported instance of esophageal carcinoma that was initially diagnosed as diagnosis

the

3.

4.

5.

as a primary

spontaneous U

6.

Buckner CB, Harmon BH, Pabbin JS. radiology of abnormal intrathoracic Probl Diagn Radiol 1988; 17:37-71.

The air. Curr

7.

132

#{149} Radinlncv

formation

confirm to the

the

diagnosis

air, which

of pneu-

is suggestive

pencardium.

Cimmino CV. Some radio-diagnostic notes on pneumomediastinum, pneumothorax and pneumopericardium. Va Med Mon 1967; 94:205-212. Mirvis SE, Indeck M, Schorr RM, Diaconis

Posttraumatic

tension

pneumopericar-

dium: the “small heart” sign. Radiology 1986; 158:663-669. Katzir D, Klinovsky E, Kent V. et al. Spontaneous pneumopenicardium: case report and review of the literature. Cardiology 1989; 76:305-308. Romhilt DW, AlexanderJW. Pneumopyopericatebium secondary to perforation of benign gastric ulcer. JAMA 1965; 191:152154. Beaugie JM, Eadie DG, Dyer NH. Pneumopericardium complicating carcinoma of the stomach. BrJ Surg 1966; 53:645-648. Robson RH. Hydropneumopericardium and oesophagitis: a non-fatal case. Thorax 1979;

8.

helps

extraluminab

JN.

References I.

and

periesophageal

.,

Figure 3. Esophagogram ministration of diatrizoate onstrates an irregular mass racic esophagus. Esophageal also noted.

obtained after admeglumine demin the mid-thoperforation was

34:262-264.

Dassel PM, Kirsh bE. Non-traumatic mopericardium and pyopneumopericardium: report of two cases. Radiology 63:346-351.

pneu1954;

January

1992