A 77-year-old woman with a history of abdominal aortic aneurysm, chronic obstructive pulmonary disease, and Nissen fundoplication surgery for a hiatal hernia 10 years ago was admitted with a 1-day history of sudden-onset sharp retrosternal chest pain radiating to the back. She was hemodynamically stable. Chest x-ray and computed tomography (CT) scan of the chest showed evidence of a significant pneumomediastinum and pneumopericardium with the greatest anterior depth of 3.8 cm (A and B) . No

more »

... onary blebs were present on CT. Physical exam was positive for Hamman crunch and pulsus paradoxus of 15 mm Hg. Esophagram, bronchoscopy, and esophagogastroduodenoscopy failed to show any evidence of fistulas. Transthoracic echocardiogram showed no evidence of cardiac tamponade. The patient underwent thoracic exploratory surgery and intraoperative insufflation of the stomach, revealing a gastropericardial fistula at the fundoplication wrap that was repaired. The pericardium was thickened and inflamed (C). The patient's pneumopericardium resolved, and follow-up imaging at 6 months showed no recurrence.