Postgastrectomy benign gastrojejunocolic fistula

Fernando A.M. Herbella; Jose C. Del Grande; Howard L. Beaton

A 66-year-old man presented with a history of diarrhea (10 bowel movements per day) for 3 months. Besides weight loss (20 kg), no other symptoms were manifested. Abdominal physical examination was normal. His medical history was marked by a partial gastrectomy due to peptic disease 10 years earlier (BII reconstruction). A colonoscopy evidenced an inflammatory ulcerative process in the transverse colon. An upper endoscopy (Fig. 1) revealed an ulcer in the gastroenterostomy. A barium enema was performed and the radiograph is shown in Figure 2.

FIG. 1

Upper endoscopy shows an ulcer in the gastroenterostomy of a partial gastrectomy.

FIG. 2

Barium enema radiograph reveals passage of contrast to the gastric pouch and jejunum limb used for the gastroenterostomy.

Gastrocolic fistula was first described by Czerny in 1903. It may be caused by a myriad of diseases, such as cancer of the colon and stomach, trauma, ulcerative colitis, diverticulitis, intraabdominal abscesses, syphilis, tuberculosis, peritonitis, peptic ulcer and after operations on the stomach or colon. Postgastrectomy gastrojejunocolic fistula reached an incidence of 8% to 22% in patients with recurrent ulcers in a prevagotomy era and when gastrectomy for peptic disease was a common operation.1 Today the disease is rare because of the decrease in surgery for peptic disease and better clinical control of recurrent ulcers; however, because the condition can occur 20 years after the initial surgery, some cases are still reported.2

Colonoscopy is frequently performed, particularly because of history of diarrhea, which is the most common symptom; however, it lacks sensibility and specificity.2 Gastroscopy might show a stomal ulcer or the fistula.2 Barium enema remains the main diagnostic tool, correctly diagnosing the fistula in almost 100% of cases.1^,2 Additional findings that can be noted on barium enema radiographs are enlarged gastric rugae, dilatation of jejunal loops, jejunitis, abnormal gastroenterostomy function and gastrojejunal ulcer.3 Conversely, upper digestive series have a sensitivity of only 30%,2^,3 because most fistulae permit the passage of contrast only in a retrograde fashion.3

In the reported case, a CT was also done (not shown) and did not show abnormalities. Although most surgeons do not routinely recommend a CT scan, we believe that it is important in order to exclude extraluminal diseases that may be the cause of the fistula.

In most cases, the disease is treated with en bloc resection of the fistula and affected parts of the stomach, jejunum and colon2 (Fig. 3).

FIG. 3

Surgical specimen of an en bloc resection of the fistula and affected parts of the stomach, jejunum and colon.

Footnotes

Submissions to the Surgical Images, soft-tissue section, should be sent to the section editors: Dr. David P. Girvan, Victoria Hospital Corporation, PO Box 5375, Station B, London ON N6A 5A5 or Dr. Nis Schmidt, Department of Surgery, St. Paul’s Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6.
Competing interests: None declared.

References

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