A gastrocolonic fistula is a rare surgical presentation, typically in the setting of gastric or colonic malignancy. This report presents the first reported Australian case of a gastrocolonic fistula following upper gastrointestinal surgery. A middle-aged woman presented to emergency with a short history of severe abdominal pain, faeculent vomiting, profuse diarrhoea and weight loss. This was in the setting of a previous pylorus-preserving pancreaticoduodenectomy complicated by marginal ulceration, for which a distal gastrectomy and Roux-en-Y reconstruction was required. The rarity of gastrocolonic fistulae and non-specific presentation with diarrhoea, vomiting and weight loss can make the diagnosis challenging. The mainstay of management is surgical resection in both benign and malignant disease.

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Occam’s razor dictates that the simplest diagnosis is usually the correct one. In ascites of unknown origin, the top differentials must include cirrhosis, malignancy and cardiac failure. Investigations such as ascitic fluid cytology and computed tomography can help identify the underlying pathology, however, these investigations do not have perfect specificity and sensitivity. Thus, “normal” investigations cannot be used to completely dismiss important differentials. In a middle-aged patient with no evidence of cirrhosis or cardiac failure, Occam’s razor suggests that a surgeon thoroughly consider and definitively exclude an occult malignancy prior to removing it from the list of differentials.