BACKGROUND: Image-guided pericardiocentesis is a diagnostic and potentially life-saving intervention, yet even under guidance, rare complications can occur. Among them, bowel perforation with subsequent fecal pericarditis is an exceptionally uncommon and often under-recognized occurrence.

CASE REPORT: We describe the case of a 72-year-old man with multiple comorbidities, including acute colonic pseudo-obstruction (Ogilvie syndrome), Parkinson disease, and chronic kidney disease, who underwent urgent fluoroscopy-guided pericardiocentesis for a large pericardial effusion. After the procedure, his drain ceased to release any fluid, and he experienced progressive tachycardia. Imaging revealed that the catheter inadvertently penetrated the transverse colon, resulting in pneumoperitoneum and pneumopericardium. He required combined thoracic and abdominal surgery, including a pericardial window, controlled drain removal, primary colonic repair, and diverting colostomy. His recovery was uneventful, and he was discharged in stable condition.

CONCLUSIONS: Only a handful of similar cases are reported in the literature. Our case presents additional evidence that image-guided pericardiocentesis may be associated with an increased risk of iatrogenic bowel injury in patients with abdominal distension or colonic dysmotility. The patient was treated surgically for pericardial drainage and repair of colonic perforation, further addressing the patient’s dysmotility at the time of surgery with the creation of a diverting colostomy. Awareness of unusual drain behavior and early imaging can expedite recognition and management of this life-threatening complication.

Keywords: Pericardiocentesis, Iatrogenic Disease, Pneumoperitoneum, Pneumopericardium, Pericardial Fluid