A 56-year-old man complained of acute intermittent epigastric pain for three days with occasional irradiation to the neck, shoulder and left arm.
She was admitted to the emergency room due to chest pain of oppressive type radiating to the neck and left arm.
His personal history included: gastrectomy Billroth I for gastric ulcus nine years ago and reoperation six months later for laparotomy.
Physical examination revealed hypotension (90/60 mmHg), tachycardia (110 l.p.m.) and jugular engorgement.
Examination by equipment and systems was normal.
Analysis showed leukocytosis (19.260/mm3) with neutrophilia (85.9%), blood glucose 224 mg/dl, AST 65 IU/l, CPK 218 IU/ml, Na+ 130 prothrombin 59%.
The rest of the laboratory tests were normal.
The electrocardiogram showed ST-segment elevation in the inferior and lateral faces.
The chest X-ray showed elevated left hemidiaphragm and gas in the pericardium compatible with pneumopericardium.
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With the presumptive diagnosis of acute pericarditis the patient is admitted to the Intensive Care Unit.
A gastroduodenal study was performed with water-soluble contrast objectifying passage of contrast to the perioral cavity.
An elevated left diaphragm with medial thickening in contact with gastric fundus was intervened.
A gastro-diaphragmatic release was performed, finding an ulcer in gastric fundus perforated to the pericardium.
Fluid aspiration of the peripherical cavity was purulent.
Total gastrectomy and transmesocolic Roux-en-Y reconstruction were performed, as well as pericranial wall biopsy.
Pericardial drainage was left, as well as left pleural and abdominal cavities.
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Postoperative echocardiogram showed minimal pericardial effusion and pressures compatible with restrictive pericarditis, but with good ventricular function.
Forty-five days after surgery, the patient was reoperated on for cholecystectomy because of acute colitis.
The pathology report was perforated gastric ulcer with moderate chronic atrophic gastritis with intestinal metaplasia.
Pericardial tissue with fibrosis and partially necrotic well differentiated gastric glands consistent with adhered gastric mucosa.
Cholecystis acute.
The patient was discharged three months after the first intervention, asymptomatic, nine years later.
