A gastropleural fistula is a pathological communication between the stomach and the pleural cavity.
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Clinical presentation
Gastropleural fistula usually presents acutely, and may be related to a recent history of surgery. However, depending on the size of the fistula, patients with gastropleural fistula may have a varied presentation, and will not necessarily be significantly unwell.
Most cases present with non-specific symptoms such as epigastric pain, chest pain, cough, shortness of breath or palpitation. The suspicion for this diagnosis should be raised if these symptoms or a history of non-resolving pneumonia are associated with a recent history of gastric surgery.
If a chest tube is inserted, it may show food particles or bile.
Pathology
Different etiologies may predispose to gastropleural fistula, such as:
- gastric surgery, e.g. sleeve gastrectomy, biliopancreatic diversion
- malignancy, e.g. gastric carcinoma, ovarian carcinoma, Ewing sarcoma, renal cell carcinoma
- perforated hiatus hernia
- trauma, e.g upper gastrointestinal endoscopy, stab injuries 3
- post-chemotherapy or post-radiotherapy
Radiographic features
Plain radiography
Demonstrates associated complications such as pneumonia, lung abscess, pleural effusion, pneumothorax and hydropneumothorax.
Fluoroscopy
Contrast within the stomach (either ingested or installed through feeding tube (PEG tube)), can be seen leaking outside the stomach and reaching the pleural space. The use of water-soluble contrast is preferred.
CT
CT shortly after the ingestion of oral contrast may show contrast pooling in the pleural space. This may also allow identification of the site of the fistula.
Treatment and prognosis
If conservative measures such as parenteral nutrition or jejunal feeding fail, closure of the fistulous track is considered the treatment of choice. This can be done endoscopically 10 or surgically. The pleural collection created by the fistula may require drainage, either percutaneously, or concurrently with surgery.
History and etymology
It is thought to have been first described by Markowitz and Herter in 1960.
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