The chest x-ray shows a markedly enlarged cardiac silloutte which is

consistent with a pericardial effusion. This finding has been termed "waterbottle heart". The most common cause is metastatic cancer. Other causes
include viral, auto-immune (rheumatoid arhtritis or SLE), trauma, or fluid
overload from any cause (liver failure, nephrotic syndrome, congestive heart
failure). The concern is for the development of cardiac tamponade in which
the pericardial pressure is elevated due to the effusion resulting in collapsing
of the right atrium or ventricle (lowest pressure chambers). This decreases
the cardiac output causing hypotension, dizziness, and eventually death. The
only treatment is pericardiocentesis.

Associated with hypertesion and cystic medial necrosis (Marfans). Typically seen in
the ascending portion of the aorta. Can lead to hemopericardium and cardiac
tamponade and a resultant MI. It can also result in aortic rupture and death. The
most common site of rupture is the aortic isthmus.
FA2012 p295

What is cardiac tamponade?

This term is used for the compression of the heart by fluid accumulating in the pericardial
cavity. The fluid may accumulate insidiously, as in chronic effusive pericarditis, or
suddenly, as in acute hematopericardium. Compression of the heart prevents diastolic
dilatation of atria and ventricles. Heart failure results in increased back pressure in the
lungs and the systemic venous circulation.
Beck triad (hypotension, increased jugular venous pressure, and muffled heart sounds) is
a typical clinical finding, but more often patients show only signs of cardiac shock, such
as hypotension, tachycardia, dyspnea, and increased venous pressure. Pulsus paradoxus is
recognized as decreased systolic pressure (>10 mmHg) during inspiration.
What are the causes of hematopericardium?
Acute hematopericardium may cause cardiac tamponade and death, whereas chronic
intrapericardial bleeding may be indistinguishable from effusive pericarditis. The causes
of bleeding into the pericardial cavity include:
& Arterial dissection involving the root of the aorta: One should remember that the first
part of the aorta lies within the pericardial sac. Accordingly, a rupture of the aortic wall
may cause intrapericardial bleeding.
& Trauma: Vehicular accidents and other high-speed injuries may rupture the root of the
aorta or the heart.
& Surgery: Small amounts of blood are regularly found in the pericardial cavity after
cardiac surgery (postcardiotomy states), but massive bleeding is uncommon.
& Bleeding disorders: Thrombocytopenia that accompanies leukemia is probably the
mostcommon cause, but bleeding may also occur in aplastic anemia, following radiation
and even severe vitamin C deficiency.
& Neoplasms: Malignant tumors invading the pericardial cavity (e.g., lung or esophageal
cancer extending into the pericardium), metastases involving the epicardium, and rare
epicardial primary tumors may be accompanied by serous or hemorrhagic effusions.