Figure 21b. Gastropericardial and esophagopericardial fistulas. (a) Transverse contrast-enhanced CT scan in an 82-year-old woman with spontaneous pneumopericardium (P) shows hiatal hernia with inflammatory changes (arrowheads) adjacent to the pericardium. Gastropericardial communication (arrow) is suggested and was confirmed at fluoroscopic examination with water-soluble contrast agent (not shown). A penetrating benign gastric ulcer was the underlying cause. (b) Oblique esophagogram in a 73-year-old man with spontaneous pneumopericardium after distal esophagectomy for cancer shows contrast agent filling the pericardial space (arrowheads) via the esophagopericardial fistula. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)