Purulent Pneumopericardium From a Gastropericardial Fistula 30 Years After Gastrectomy

Gastropericardial fistula is a rare and life-threatening complication, most often occurring in patients with prior gastric surgery and presenting with pneumopericardium and severe infection.

A 64-year-old man with a history of gastrectomy 30 years earlier presented with chest pain, dyspnea, and fever. Computed tomography demonstrated pneumopericardium with an air-fluid level, and pericardiocentesis yielded bile-tinged purulent fluid, findings strongly suggestive of a gastropericardial fistula. Despite broad-spectrum antimicrobial therapy and supportive care, the patient remained critically ill and left the hospital against medical advice. He died 2 weeks later from septic shock.

Gastropericardial fistula is diagnostically challenging given its rarity and nonspecific presentation. Pneumopericardium in patients with prior gastric surgery is a key diagnostic clue, and computed tomography is essential when echocardiography is limited by intrapericardial air.

Gastropericardial fistula should be suspected in patients with pneumopericardium and prior gastric surgery, and early pericardial drainage is critical.