A fatal case of gastropericardial fistula due to a benign gastric ulcer

Abstract

Gastropericardial fistula caused by a benign gastric ulcer is a rare condition, with few fatal cases documented in forensic medicine. A healthy man in his 40s presented with chest pain and fever. Pericardiocentesis produced exudative fluid with a markedly elevated adenosine deaminase level, leading to an initial diagnosis of tuberculous pericarditis and initiation of antituberculous therapy. Despite treatment, the patient deteriorated. On hospital day 43, gastric contents were observed draining from a mediastinal tube. Upper endoscopy revealed a large gastric ulcer that had perforated the diaphragm and communicated directly with the pericardial cavity. The patient died of multi-organ failure on day 55. Forensic autopsy revealed a 7-cm chronic gastric ulcer penetrating the left hemidiaphragm and forming a 1-cm fistula with the pericardial sac, and no evidence of tuberculosis. This case highlights the need to consider gastropericardial fistula in patients with unexplained pericarditis, especially if atypical effusions or alimentary material are noted in thoracic drains. Early recognition followed by urgent surgical intervention may be life-saving. Furthermore, from a forensic perspective, it highlights the need to consider gastropericardial fistulas in healthy adults with unexplained chest pain in the context of sudden death.