Irfan Ul Haq, Zahir Shah, Riaz Anwar Bashir.
Pneumopericardium: a very unusual cause.
Pak Armed Forces Med J Jan ;53(2):239-41.

A 39 year old pensioner soldier admitted with history of absolute constipation, abdominal distension and vomiting for last 4 days. Patient was not passing even flatus. Vomitus contained food residue and there was no blood in it. Patient was also having 101F temperature at the time of admission. In past history patient had a stab wound in left upper abdomen about 4 years back for which he remained hospitalized for a few days and was managed conservatively. On examination there was a scar mark in left hypochondrium. Patient was admitted in surgical ward as a case of intestinal obstruction with suspected peritoneal adhesions secondary to old stab wound as a probable cause. Initial investigations revealed distended small gut loops on plain abdomen X-ray films. Total leukocyte count in blood complete picture was 7.5 x 109/L. On the same day, after few hours of admission, patient suddenly developed respiratory distress. Medical specialist was called in. He examined the patient and made the provisional diagnosis of cardiac tamponade. Chest X-Ray was done immediately which revealed massive pneumopericardium. Large amount of air was present in pericardial cavity with a few soft tissue densities in chest along the left dome of diaphragm. A needle was introduced into pericardial cavity to remove the gases, which gave a bit of relief to the patient. Nasogastric tube was passed and water soluble radiographic contrast medium given into stomach through this tube. A portable X Ray of chest and upper abdomen ruled out herniation of stomach into thorax. Emergency exploratory laparotomy revealed a rent in left dome of diaphragm with herniated gangrenous perforated transverse colon into the pericardial cavity.

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