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Ann Med Surg (Lond)
Ann Med Surg (Lond)
MS9
Annals of Medicine and Surgery
2049-0801
Lippincott Williams & Wilkins Hagerstown, MD

AMSU-D-24-00472
10.1097/MS9.0000000000002415
00099
3
Case Reports
Strangulated pericardial hernia presenting as a case of STEMI; when the disease misleads the physician: a very rare case report
Omar Asaad Shareef MD aasaad.omar@uod.ac

Musa Dildar Haji adildar@uod.ac

https://orcid.org/0000-0002-8358-6208
Sgery Azri Salih Haji MD b*azrysgery23@gmail.com

a Department of Surgery, College of Medicine, University of Duhok
b Directorate of Health, Duhok, Kurdistan Region, Iraq
* Corresponding author. Address: Directorate of Health, Duhok, Kurdistan Region, Iraq, Kurdistan Region, Iraq. Tel.: +96 475 0183 0954. E-mail: azrysgery23@gmail.com (A. S. H. Sgery).
9 2024
7 8 2024
86 9 55865589
8 3 2024
22 7 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0/

Introduction and importance:

The pericardial hernia is a rarely encountered clinical condition characterized by the herniation of the abdominal viscera into the pericardial cavity. Trauma precedes the development of these hernias in most cases, yet iatrogenic intervention and congenital defects are other potential causes.

Case presentation:

A male aged 60 years, with no history of previous trauma, presented with epigastric pain and was diagnosed with a case of STEMI. After the treatment, the patient continued to deteriorate and developed repeated vomiting. Surgical consultation was counseled which recommended a plain erect abdominal radiograph that revealed air-fluid levels. During surgery, the surgeon noticed a strangulated jejunum protruding into the pericardium, and the case was diagnosed as a pericardial hernia.

Clinical discussion:

Pericardial hernias could be congenital or acquired and trauma is regarded as the commonest cause in adults. According to the history and clinical presentation the cause could be an old-forgotten trauma that has led to the small defect formation and protrusion of the jejunum. Trauma is regarded as the commonest cause; however, cases can pass unnoticed. The clinical presentation of this patient was initially related to acute coronary syndrome and was treated with primary coronary intervention, later a co-existing cause or probably the initiating cause was found to be a pericardial hernia.

Conclusion:

The diagnosis of the case makes a significant challenge that requires a high index of suspicion due to the rarity of the condition, variable clinical presentation, and the delayed development of symptoms.

Keywords:

case report
pericardial hernia
STEMI
strangulated hernia
trans diaphragmatic-pericardial hernia
OPEN-ACCESSTRUE
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pmcIntroduction

Highlights

Development or failure of resolution of the symptoms after appropriate management should raise the suspicion of another diagnosis, the development of a complication or the presence of pathology other than what is seen.

The diagnosis of pericardial hernia requires a high index of suspicion.

These hernias can be a two-way path; usually organs from the abdominal cavity pass into the pericardium, the heart can slip away into the abdomen or even the lungs.

Hernia is the protrusion of content through an established defect1. Herniation, protrusion, of abdominal viscera into the pericardial sac through the diaphragm is known as the pericardial hernia2. Diaphragm, a dome-shaped multi-layers muscle sheath with a principal role in respiration and anatomically that separates the thoracic cavity from the abdominal cavity, is the gate through which the abdominal contents herniate into the pericardial sac3. Pericardium, situated in the thoracic cavity, contains the heart and the great vessels in a flask-shaped sac4. There are two known potential factors found to play a role in the development of pericardial hernia: increased intra-abdominal pressure and potential defect in the diaphragmatic wall2, process takes place via the aid of pressure difference5. The clinical presentation of the disease varies and cannot be identified clearly due to the rarity of the disease; however, the mean age of the presentation is 55.86±15.79 years, with men being more commonly encountered with the disease2.

In this article, we present one of the rare clinical cases that could be encountered in the medical practice; strangulated pericardial hernia presenting with clinical features suggestive of STEMI in a 60-year-old man, with no history of trauma.

Case presentation

A 60-year-old male presented to the hospital/emergency department, with no history of trauma, chiefly complaining of severe, vague pain in the epigastric region associated with shortness of breath which was going on for one day duration and worsening overtime. Electrocardiogram (ECG) was done and revealed inferior ST-segment elevation myocardial infarction (STEMI) (Fig. 1), and Serum troponin (S. troponin) was 527 nannogram/l (reference range for males <50 ng/l). The patient was treated for acute coronary syndrome (ACS) with primary coronary intervention (PCI) and admitted in the coronary care unit (CCU) for 2 days, his PCI report was missing; however, 2 stents were placed. Later, for a proper patient evaluation, surgical consultation was requested due to the deteriorated clinical condition from constipation, and persistent vomiting, with no response to treatment. The latter findings directed the case toward a suspected intestinal obstruction. An erect abdominal X-ray was done and demonstrated multiple air-fluid levels (Fig. 2). The case was concluded as a case of intestinal obstruction and sent to the operation theater. On laparotomy, the surgeons found a right-sided, small (<2 cm) diaphragmatic defect (Fig. 3) through which a gangrenous loop of the jejunum protruded into the pericardium. Surgical resection was performed for the gangrenous portion of the intestine (Fig. 4), followed by end-end anastomosis, and the diaphragmatic defect was closed by stitches. On day three postoperatively, the patient was discharged home with no complications.

Figure 1 ECG showing inferior myocardial infarction (inferior ST-segment elevation myocardial infarction).

Figure 2 Erect abdominal X-ray of the patient showing multiple air-fluid levels.

Figure 3 The small defect in the diaphragm connecting abdomen to thoracic cavity.

Figure 4 Resected part of the gangrenous portion of the intestine.

Discussion

The herniation of abdominal viscera into the pericardium is called pericardial hernia, which is one of the rare hernias encountered in clinical practice, possessing a significant challenge for the sake of diagnosis2. A pericardial hernia is a rarely clinically encountered disease, with the exact incidence remaining vague2.

The disease has a variable clinical presentation ranging from asymptomatic, incidental finding to the diagnosis upon the development of symptoms related to gastrointestinal or cardiorespiratory systems2. Additionally, patients can present with emergencies such as cardiac tamponade6 or STEMI, as in our case. In our case, the patient developed persistent vomiting despite the treatment. Following a surgical consultation, a plain erect abdominal radiograph was ordered and aided in the diagnosis by demonstrating air-fluid levels. Shockingly, the strangulated pericardial hernia was found instead of the other commoner forms of intestinal obstruction intraoperatively.

The main etiologies identified were trauma 56.5% mainly as a result of blunt injury or falls, iatrogenic interventions 30.6% especially those that involved manipulation of the diaphragm (incision or creation of an orifice for reaching the pericardium), and congenital-defect 12.9%2,5,7,8. The development of diaphragmatic hernia following trauma is noticed mainly on the left hemidiaphragm, and less commonly on the opposite side due to the protective role of the liver on the opposite hemidiaphragm9. Additionally, patients with trauma or congenital defects presented at a younger age of ~10 years younger than those with iatrogenic hernia2.

The most common abdominal content encountered that protrudes through the diaphragm into the pericardial cavity was the transverse colon 49.4%, followed by the greater omentum 48.2%, and the small intestine 37.6%2. In our case, the jejunum was the herniated organ.

Pericardial hernias could be congenital or acquired. In adults, trauma is the commonest cause2,10, which can be attributed to the sudden rise in the intra-abdominal pressure following the contact leading to the formation of a linear tear. The size could initially be relatively small not allowing any herniation. Later, the effect of episodes of increased intra-abdominal pressure from coughing, lifting, straining, or other factors, the tear can gradually increase in size and allow herniation10, thus a delayed and query presentation2,10. Despite denying any trauma, it is possible that an old trauma happened, forgotten by the patient yet not his diaphragm.

The duration behind the development of pericardial hernia and the development of symptoms could be a couple of days following trauma or operation or could take longer, possibly many years2,6,11. Hence the diagnosis becomes challenging as cases pass unnoticed due to the delayed presentation of symptoms. Moreover, their presentation might not guide directly toward the diagnosis12; in our case, the patient presented with severe pain in the epigastric region, with no history of trauma, probably forgotten by the patient, and diagnosed as a case of inferior STEMI following typical ECG and clinical findings.

Chest/abdominal radiography, echocardiogram, and computed tomography are useful investigations for diagnosis, with the latter being the gold standard2. In our case, intestinal obstruction was suspected from the history and abdominal radiography demonstrating air-fluid levels. Yet, during surgery, the final diagnosis was made, similar to another case seen intraoperatively6.

Pericardial hernias are treated via surgery where the herniated content is reduced back into the abdominal cavity±resection of the gangrenous part, as in our case, followed by the surgical closure of the defect2. The data for the best approach is limited, yet in acute presentations, an abdominal approach is recommended for a clearer surgical field and better access to the diaphragm2. The possible life-threatening postoperative complications include stomach volvulus, ventricular fibrillation, and acute respiratory distress syndrome2.

Finally, these hernias can be a two-way path; in the usual case, organs from the abdominal cavity pass into the pericardium, and nonetheless, the heart can slip away into the abdomen13.

Conclusion

The herniation of abdominal viscera into the pericardium is quite a rare condition to be encountered in clinical practice. Diagnosis requires a high index of suspicion and a systematic approach in order not to miss such rare cases. Patient’s clinical presentation can be vague thus; a stepwise approach remains the single best choice for assessing and treating such cases. A multi-disciplinary collaboration will be needed for the diagnosis and management of pericardial hernias for optimal patient care.

Scare criteria

The work has been reported in line with the SCARE 2023 criteria14.

Ethical approval

Ethical approval was provided by author’s institution. University of Duhok, College of Medicine.

Consent

Written informed consent was obtained from the patient/legal guardian for publication of this case report and accompanying images. A copy of written consent is available for review by the Editor-in-Chief of this journal on request.

Source of funding

Not applicable.

Author contribution

D.H.M. and A.S.O. diagnosed the case. D.H.M. and A.S.O. performed the operation and followed up the case. A.S.H. took the history and wrote the first draft. All authors revised and approved the final paper.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Asaad Shareef Omar.

Data availability statement

Data are publically available.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
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