Acute Pericarditis as a Complication of Hiatal Hernia Perforation

Acute pericarditis is a serious and potentially fatal disease in which a diagnostic workup is not always straightforward. Hiatal hernia, on the other hand, is often asymptomatic and can be easily diagnosed if symptomatic. In advanced forms of hiatal hernia, oppression of intrathoracic organs and heart failure can occur. In uncommon cases, the large intestine can also be translocated into the chest cavity, and very rarely, it can be perforated with the development of mediastinitis and/or pericarditis. We report the case of a 74-year-old female with a 1.5-month history of chest pain with elevated inflammatory markers. This patient was empirically treated with antibiotics for suspected pneumonia. After a few weeks, due to a worsening of the patient's condition, an echocardiogram and then a CT of the chest were performed, showing a large hiatal hernia and a very probable purulent pericarditis, necessitating a surgical exploration. A cardiac surgeon found stercoral contents in the pericardium, with a fistula at the apex of the heart. The operation continued with an exploration of the abdominal cavity; the general surgeon returned the massive hiatal hernia to the abdomen, the contents of which were the stomach and transverse colon. An extensive perforation in the transverse colon was found. Lavage, drainage, and resection of the affected part of the intestine were performed, and a permanent (terminal) colostomy was constructed. The patient was in severe septic shock with multiorgan failure and died 10 hours after surgery despite maximal therapy. This case highlights the importance of interdisciplinary cooperation and the importance of considering the possible fistula in the co-occurrence of hiatal hernia and pericarditis.