Guts in the heart- literally!!

Diaphragmatic hernia is a birth defect where there is a hole in the diaphragm (the large muscle that separates the chest from the abdomen). Organs in the abdomen (such as intestines, stomach, and liver) can move through the hole in the diaphragm and upwards into a patient's chest. When an organ pushes through the hole, it is called a hernia.

Intrapericardial diaphragmatic hernia (IPDH) is defined as prolapse of the abdominal viscera from the peritoneal cavity into the pericardium. IPDH often presents with symptoms of bowel obstruction, such as abdominal discomfort or vomiting. If not properly treated, life-threatening necrosis and/or perforation of the herniated contents may occur. IPDH is often a congenital etiology, but it may also be caused by prior trauma or interventional and surgical procedures.

IPDH is the rarest of all non-hiatal diaphragmatic hernias, is a sacless hernia. It can have a traumatic, congenital, or iatrogenic etiology. Among these three etiologies, an iatrogenic cause is extremely rare. Iatrogenic IPDHs have reportedly occurred after coronary artery bypass grafting using a right gastroepiploic artery graft  and subxiphoid epicardial pacemaker insertion through a pericardial-peritoneal window. 

The present case is unique since it the cause was probably a history of surgery for constrictive pericarditis. The unique scenario of applications being relieved by belching or defecating gives a strong hint to a mixed cardiac-gastro etiology. 

Source NEJM DOI: 10.1056/NEJMicm2028463