Intrapericardial bowel hernia with cardiac tamponade.

An intrapericardial hernia resulting from an episode of blunt trauma six years prior to injury presented as acute intestinal obstruction accompanied by acute cardiac tamponade. This occurred three months following elective repair of a totally separate left diaphragmatic hernia. Both hernias were presumed to have resulted from the same traumatic incident, as both were devoid of hernial sacs. This is the second such case in which acute tamponade has been documented, and in both cases reduction of the hernia was followed by prompt resolution of tamponade. CASE HISTORY A 58-year-old semiskilled labourer was the front-seat passenger in a car involved in a frontal collision with another vehicle in 1978. He received an injury to the left lateral chest wall. He complained of severe left lower chest pain exacerbated by breathing. On examination, there was bony crepitus on springing the left lateral chest wall. There was poor entry to the left base which was dull to percussion. A chest X-ray revealed fractures of the left fifth to seventh ribs in the anterior axillary line with a small left basal effusion. A basal chest drain was inserted but removed after 24 hours following only minimal serosanguinous drainage. He was discharged from hospital four days later with only minimal left thoracic discomfort. At review over the next six months, he was noted to have a slowly resolving left basal effusion associated with persistence of left chest discomfort. By 1980, he had been complaining of increasingly severe upper gastrointestinal symptoms, including heartburn, vomiting and, on one occasion, possible haematemesis, following which he was referred for oesophagogastroscopy. This showed a hiatus hernia, mild gastritis and a normal duodenum. He was prescribed cimetidine with minimal relief of symptoms. In 1983, he was admitted to hospital with acute, severe central abdominal pain associated with diarrhoea, both of which symptoms settled spontaneously. It became evident that he had been suffering from increasingly severe intermittent epigastric pain, with pain referred to the left shoulder, of being 'short of breath