Abstract Gastropleural fistula (GPF) is a rare but life-threatening communication between the stomach and pleural cavity. It usually results from trauma, infection, or postoperative complications. Malignancy-associated GPFs are exceedingly uncommon, with only a few reported cases. We present a unique case of GPF secondary to direct invasion of gastric adenocarcinoma into the pleural space. A 54-year-old female with metastatic gastric adenocarcinoma involving the peritoneum and intra-abdominal lymph nodes presented with acute left-sided chest pain described as a spasm radiating to the back, associated with shortness of breath but no fever, cough, or sputum. On presentation, she was tachycardic (HR 130-140 bpm), afebrile, with SpO2 94% on room air and normal blood pressure. Physical examination revealed markedly diminished breath sounds on the left.Laboratory evaluation showed leukocytosis (WBC 20.1 × 109/L), lactate 3 mmol/L, BNP 233 pg/mL, and troponin 11 ng/L. EKG revealed sinus tachycardia. Chest radiograph showed left lung opacification suggestive of a large effusion and retrocardiac consolidation. CTA chest demonstrated a gas- and fluid-filled loculated collection (5.9 × 5.7 × 4.8 cm) in the left pleural cavity contiguous with a perforated gastric mass invading the spleen, pancreas, and left hemidiaphragm—findings diagnostic of a gastropleural fistula. No esophageal perforation was seen.The patient was started on broad-spectrum antibiotics. Thoracic surgery placed a left-sided chest tube, leading to complete resolution of the hydropneumothorax. Given extensive metastatic disease, surgical repair of the fistula was deferred. A venting gastrostomy and feeding jejunostomy were placed to divert enteric flow and promote closure. She was continued on prolonged antibiotics and nutritional support. Follow-up imaging at two months showed near-complete resolution of the hydropneumothorax, and the chest tube was removed. At four months, CT imaging demonstrated closure or decompression of the fistula with residual scar tissue and no recurrent pleural fluid or gas. Gastropleural fistula secondary to gastric adenocarcinoma is exceedingly rare. The mechanism likely involves tumor necrosis and diaphragmatic invasion. Diagnosis requires high suspicion in cancer patients with new-onset pleural effusion or hydropneumothorax. CT imaging is key for delineating the fistulous tract. Management depends on disease stage; palliative measures such as drainage and enteral diversion may provide symptom relief and spontaneous closure in inoperable cases. Malignant GPF is a rare but critical complication of gastric adenocarcinoma. Early recognition, multidisciplinary care, and individualized management are essential for improving outcomes. This abstract is funded by: None
Adam et al. (Fri,) studied this question.