Crosstalk Between Cavities: Pericardiocentesis-Related Colonic Injury in a Post-Bariatric Patient

Introduction: Pericardiocentesis is a critical, generally safe procedure for cardiac tamponade when guided by imaging. However, rare iatrogenic complications can cause significant morbidity. We present a rare case of transcolonic perforation with peritonitis and pneumopericardium following percutaneous pericardiocentesis in a patient with complex postoperative anatomy, highlighting risks in individuals with surgically altered intraabdominal structures.


Description: A 69-year-old male with history of Roux-en-Y gastric bypass and recent Graham patch repair for a perforated ulcer developed stress-induced cardiomyopathy in the setting of an intra-abdominal infection. Echocardiogram showed a large pericardial effusion with tamponade physiology, prompting fluoroscopic-guided pericardiocentesis with drainage of 120 cc of blood-tinged fluid and catheter placement. Within 12 hours, the patient developed acute hypotension concerning for obstructive shock. Point-of-care ultrasound showed a poor cardiac window; CT revealed pneumoperitoneum and pneumopericardium, with the pericardial drain traversing the transverse colon into the pericardial space. Exploratory laparotomy found murky fluid in both peritoneal and pericardial cavities. Cultures grew enteric organisms including E. coli, Klebsiella, Bacteroides, and E. faecalis, consistent with fecal contamination. A pinpoint colotomy and tracking diaphragmatic defect were identified as the presumed catheter path. The patient underwent colotomy repair and pericardial washout, recovered well, and was discharged to rehab on a 4-week antibiotic course.


Discussion: Pericardiocentesis is generally safe, but transcolonic perforation is rare, with four prior reports often involving distorted anatomy like Chilaiditi syndrome. In this case, prior Roux-en-Y bypass and ulcer repair likely caused adhesions and anatomical shifts, positioning the colon near the pericardium. Despite image guidance, these changes led to inadvertent transvisceral catheter placement. This highlights the need for thorough preprocedural evaluation in patients with altered GI anatomy. When imaging is limited, cross-sectional imaging or alternate access routes should be considered. Early recognition and surgical intervention were key to a favorable outcome in this rare, life-threatening complication.