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Gastrocolic Fistula

A gastrocolic fistula is an abnormal channel that develops between the stomach and intestine (colon), allowing for the communication of these two structures.


Presentation

A patient affected by a gastrocolic fistula is subject to a considerable loss of fluid and electrolytes, as well as malnutrition and inadequate concentration of vitamins. The most typical symptoms an individual will present with are nausea, possibly accompanied by frequent episodes of emesis, diarrhea, considerable weight loss and abdominal pain. Patients often report fecal halitosis, namely a particularly obnoxious smell in their breath. The normal process of digestion cannot be achieved when a person has a gastrocolic fistula; therefore, gastric contents are transferred to the colon too rapidly and the diarrhea episodes are acidic, sometimes accompanied by steatorrhea, caused by the gastrointestinal tract's inability to digest properly. In general, although diarrhea is one of the most typical and predominant symptoms, it may not always be present; patients can sometimes suffer from constipation instead. Although it is a rare observation, some patients may experience episodes of melena or hematemesis.

Children, even that are few weeks old can also be affected by a gastrocolic fistula, since completely spontaneous occurrences have also been reported. Children usually present with frequent vomiting and an increased appetite accompanied by weight loss [9].

Severe complications may follow a gastrocolic fistula that has been left undiagnosed or untreated, especially when it has formed on a malignant background. Sepsis, metabolic disorders, respiratory, renal and hepatic failure may develop and threaten the life of a patient. Pancytopenia is observed as a complication arising from the hemopoietic system and multiple organ system failure syndrome can arise as well.

Weakness
  • An individual with a gastrocolic fistula presents with symptoms such as diarrhea, nausea, loss of weight, emesis, anemia, fatigue, weakness and abdominal pain.[symptoma.com]
  • He presented in a setting of hypovolaemia with a weak pulse of 90/min and a BP of 100/70 mmHg, random blood sugar was 100mg/dl.[panafrican-med-journal.com]
Melena
  • Abstract Abdominal pain, diarrhea, weight loss, vomiting, foul eructation, feculent vomiting and melena are among the presenting symptoms of patients with a gastrocolic fistula.[ncbi.nlm.nih.gov]
  • The authors hereby report a 54-year-old man with a 2 months history of weight loss, watery diarrhoea, fecal halitosis and melena. Laboratory tests showed severe anaemia and hypoalbuminaemia.[ncbi.nlm.nih.gov]
  • Although it is a rare observation, some patients may experience episodes of melena or hematemesis. Children, even that are few weeks old can also be affected by a gastrocolic fistula, since completely spontaneous occurrences have also been reported.[symptoma.com]
  • Patient was also complaining of chronic bloody diarrhea, mostly melena. Had only one episode of bright red blood per rectum, and one episode of vomit (digested food with no blood), both occurring in the 24 hours prior to seeking medical care.[ijcasereportsandimages.com]
Upper Abdominal Pain
  • We report a cachectic 82-year-old woman who presented with upper abdominal pain, diarrhoea, loss of weight and loss of appetite.[ncbi.nlm.nih.gov]
  • The patient was a 58-year-old man who was hospitalized with upper abdominal pain. He was diagnosed as having a gastric ulcer, and was prescribed a proton pump inhibitor (PPI), but did not comply with the medication.[ncbi.nlm.nih.gov]
  • A 65-year-old man was presented with weight loss, nausea, vomiting, diarrhea, fatigue, foul-smelling eructation, and upper abdominal pain for the last 2 months.[ncbi.nlm.nih.gov]
  • Abstract A 72-year-old woman was admitted to our hospital complaining of loss of weight, general fatigue, and upper abdominal pain.[ncbi.nlm.nih.gov]
Steatorrhea
  • It may produce a devastating syndrome which includes diarrhea, weight loss, malnutrition, anemia, and steatorrhea.[mdedge.com]
  • The normal process of digestion cannot be achieved when a person has a gastrocolic fistula; therefore, gastric contents are transferred to the colon too rapidly and the diarrhea episodes are acidic, sometimes accompanied by steatorrhea, caused by the[symptoma.com]
Recurrent Abdominal Pain
Increased Appetite
  • Children usually present with frequent vomiting and an increased appetite accompanied by weight loss.[symptoma.com]
Arthritis
  • Abstract An unusual case is presented of a benign gastrocolic fistula occurring in a 70-year-old man treated with piroxicam for arthritis for a period of only two months.[ncbi.nlm.nih.gov]
  • By age 9, she developed intermittent arthritis and at 10 years was diagnosed with Crohn's disease by barium enema and colonoscopy with biopsy. Gastrointestinal involvement was limited to the transverse colon.[journals.lww.com]

Workup

During the physical examination, the abdominal region can be palpated as tender and distended. The abdominal walls elicit spasms and a mass may be felt in some cases. Patients are normally not febrile and an examination of the rectum is expected to reveal no blood. In general, almost half of the patients affected by a gastrocolic fistula present with some abnormal findings in the initial physical abdominal examination.

The laboratory findings include:

Even though a diagnosis can be achieved, based on the patient's medical history and clinical manifestations, imaging modalities play a significant role in the establishment of a definitive and precise diagnosis. A plain radiograph can help to differentiate between a dysfunctional anastomosis performed previously for peptic ulcer and a potential gastrocolic fistula. The examination that can set the decisive diagnosis, however, a barium enema is diagnostic in almost every single case. A colonoscopy or gastroscopy are not recommended since the fistula opening is many times not discernible amongst the foldings of the gastrointestinal tract;however, they also play a role in diagnosing a gastrocolic fistula, since they can eliminate the possibility of another condition that can produce the same symptomatology. A computerized tomography scan can help to pinpoint the exact location of the fistula and plan an effective surgical intervention.

Gastric Fistula
  • Overview MeSH Major Colon, Sigmoid Endoscopy, Gastrointestinal Gastric Fistula Intestinal Fistula Sigmoid Diseases authors Nici, A. Hussain, S. Rubin, Mark A.[vivo.med.cornell.edu]
  • Fistula Humans Intestinal Fistula Male Methods Middle Aged Peptic Ulcer Perforation Stomach Ulcer[scholars.duke.edu]
  • Examples include gut - gut: entero-enteric fistula colo-enteric fistula colo-duodenal fistula colo-gastric fistula gut - skin: enterocutaneous fistula gastro-cutaneous fistula colo-cutaneous fistula certain peri-anal fistulas gut - bladder: entero-vesical[radiopaedia.org]
  • Gastric fistula : from the stomach to the skin surface (K38.3) Fistula of appendix ( K60.3 ) Anal fistula ( K60.3 ) Anorectal fistula : connecting the rectum or other anorectal area to the skin surface.[wikidoc.org]
  • Gastric fistula : from the stomach to the skin surface (K38.3) Fistula of appendix ( K60 ) Anal and rectal fissures and fistulas ( K60.3 ) Anal fistula ( K60.5 ) Anorectal fistula (fecal fistula, fistula-in-ano): connecting the rectum or other anorectal[en.wikipedia.org]
Gastric Fistula
  • Overview MeSH Major Colon, Sigmoid Endoscopy, Gastrointestinal Gastric Fistula Intestinal Fistula Sigmoid Diseases authors Nici, A. Hussain, S. Rubin, Mark A.[vivo.med.cornell.edu]
  • Fistula Humans Intestinal Fistula Male Methods Middle Aged Peptic Ulcer Perforation Stomach Ulcer[scholars.duke.edu]
  • Examples include gut - gut: entero-enteric fistula colo-enteric fistula colo-duodenal fistula colo-gastric fistula gut - skin: enterocutaneous fistula gastro-cutaneous fistula colo-cutaneous fistula certain peri-anal fistulas gut - bladder: entero-vesical[radiopaedia.org]
  • Gastric fistula : from the stomach to the skin surface (K38.3) Fistula of appendix ( K60.3 ) Anal fistula ( K60.3 ) Anorectal fistula : connecting the rectum or other anorectal area to the skin surface.[wikidoc.org]
  • Gastric fistula : from the stomach to the skin surface (K38.3) Fistula of appendix ( K60 ) Anal and rectal fissures and fistulas ( K60.3 ) Anal fistula ( K60.5 ) Anorectal fistula (fecal fistula, fistula-in-ano): connecting the rectum or other anorectal[en.wikipedia.org]

Treatment

In order to effectively treat a patient affected by a gastrocolic fistula, surgical intervention is necessary. Prior to surgery, the patient receives supportive therapy for a successful preparation to be possible. The preparation includes the following:

  • The patient's diet is modified to include food rich in protein and carbohydrates since malnutrition exerts negative effects on their concentrations.
  • Electrolyte imbalance needs to be corrected prior to surgery.
  • Individuals may receive blood transfusions if anemia is present.
  • Vitamin C and B supplementation
  • Parenteral nutrition
  • Antibiotic coverage as a precaution before surgery, comprising mainly tetracyclines or aminoglycosides

In the past, the indicated surgical procedure was limited to the resection of the fistula, followed by a Billroth I or II anastomosis. However, due to the failure of this protocol to achieve a definitive closure of the fistula, it is presently recommended that a colostomy is first performed, in order to prepare the colon for the excision; the colon is reconnected after 3 or 4 months. Given the fact that gastrocolic fistulae usually develop due to an underlying malignancy and patients often suffer from various comorbidities, each surgical therapeutic plan needs to be individualized. Many patients also receive chemotherapy or radiation therapy after surgery, so as to complete the malignant disease's treatment protocol. The surgical procedures applied to treat a gastrocolic fistula cause few complications, such as abdominal abscesses, hemorrhage and, potentially, peritonitis.

As an alternative to open surgery, an endoscopic injection of a somatostatin can also be attempted in cases of fistulae forming due to the presence of peptic ulcers. Exclusively pharmacologic therapy can also be attempted in these cases, as many patients can benefit from the administration of protein pump inhibitors (PPIs) and achieve a resolution of the fistula in two to sixteen weeks [11].

Prognosis

Prognostic markers for a gastrocolic fistula are poor, not due to the severe mortality/morbidity accompanying the fistula itself, but due to the malignant comorbidity that usually exists. Reports indicate that 10 years was the longest survival period for a patient that underwent surgical excision of a gastrocolic fistula, given that the vast majority of the patients treated for this condition simultaneously suffer from a type of gastrointestinal tract cancer. [9].

Etiology

The leading cause of gastrocolic fistulae is presently cancer of the gastrointestinal tract. Various subtypes of cancer have been incriminated for the development of gastrocolic fistulae, amongst which:

Except for malignancy, other non-malignant conditions can also account for the creation of pathologic passages between the colon and stomach. Prior to the advent of H2 antagonists, gastrocolic fistulae were very commonly caused by gastric ulcers; the introduction of effective pharmaceutical treatment, however, has reduced their incidence following peptic ulcers [4]. Nowadays the most frequently observed non-malignant causes of gastrocolic fistulae are two: abdominal adhesions following prior laparotomy and the use of non-steroidal anti-inflammatory drugs (NSAIDs) [5] [6] [7]. Additionally, gastric tuberculosis, syphilis, idiopathic inflammatory bowel disease and pancreatitis can also lead to the formation of gastrocolic fistulae.

Epidemiology

Patients who suffer from refractory peptic ulcers are expected to develop gastrocolic fistulae at a rate of 0.14%. The fistulae show a predilection for postmenopausal women, who seem to be affected twice more frequently than men in the industrialized West. In the Eastern countries, however, men are almost 3 times more frequently affected by gastrocolic fistulae than women [8].

Sex distribution
Age distribution

Pathophysiology

A gastrocolic fistula usually develops as a result of gastrointestinal malignancy. The inflammation and erosion of the walls of the GI tract's organs lead to the formation of mutual channels that allow for the communication between the two organs.

Regardless of whether the cause is of malignant nature or not, gastrocolic fistulae lead to a variety of common clinical manifestations. Fluids and electrolytes are lost, leading to malnutrition, weight loss and vitamin deficiency. Hepatic and renal function are often compromised, with evidence of pancytopenia and septic phenomena.

Prevention

Since gastrocolic fistulae occur as a complication of an underlying disease, they cannot be prevented. Close monitoring in cases of people affected by cancer of the gastrointestinal tract can potentially help to detect a fistula earlier and treat it effectively.

Summary

In general, a fistula is an abnormal channel that develops between two organs that, under normal circumstances, do not communicate. Fistulae are categorized depending on which parts of the body they connect:

  • External: Connecting internal organs to the skin
  • Internal: Connecting internal organs

Another possible classification utilizes the pathogenetic mechanism that leads to their development and further divides fistulae into the category of spontaneous and iatrogenic, with the latter occurring after a surgical procedure [1].

Gastrocolic fistula develops between the stomach and colon; the predominant cause is gastric cancer [2], although there are also benign circumstances under which such a channel may form. This include:

  • Prior laparoscopic surgery, which causes abdominal adhesions that push the stomach towards the colon. Their persisting close contact causes their walls to erode and leads to the formation of a fistula.
  • Percutaneous endoscopic gastrostomy feeding tubes: PEG feeding tubes have been incriminated for causing gastrocolic fistulae because of their risk of colon perforation.

An individual with a gastrocolic fistula presents with symptoms such as diarrhea, nausea, loss of weight, emesis, anemia, fatigue, weakness and abdominal pain. Although the first three symptoms, namely emesis, diarrhea and weight loss are believed to be the typical triad of symptoms, it is estimated that only 1/3 of the patients diagnosed with the condition initially present in such a way [3].

Patient Information

A fistula is, in general, an abnormal channel that results in communication between two organs, even though in healthy individuals they do not communicate. A gastrocolic fistula is a defective passage between the stomach and the intestine (the colon), which allows the contents of the stomach to pass on to the colon without proper digestion.

A gastrocolic fistula can develop as a result of various types of cancer (stomach, colon cancer) or as a result of non-malignant conditions, such as syphilis, peptic ulcers, surgery to the abdomen, the use of non-steroidal anti-inflammatory drugs (NSAIDs) and tuberculosis of the abdomen. Nowadays, the use of NSAIDs and a previous laparoscopic surgery to the abdomen are the two most common causes of gastrocolic fistulae.

An individual bearing such a fistula is expected to experience frequent episodes of vomiting, nausea, diarrhea and weight loss. Patients feel exhausted and weak and may complain of a particularly bad breath. Upon examination, extremely low levels of vitamins are revealed, alongside anemia; in severe cases, the lungs, kidneys, and liver may start to fail as well.

Gastrocolic fistulae are treated surgically, in order for the fistula to be completely removed. The patient first needs to follow an appropriate diet modification, in order for their general condition to improve before they can be operated on.

References

Article

  1. Stefan MM, Holcomb GW 3rd, Ross AJ 3rd. Cologastric fistula as a complication of percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr. 1989;13(5):554-6.
  2. Buyukberber M, Gulsen M, Sevinc A, Koruk M, Sari I. Gastrocolic fistula secondary to gastric diffuse large B-cell lymphoma in a patient with pulmonary tuberculosis. J Nat Med Assoc. 2009;101(1):81–83.
  3. Aydin U, Yazici P, Ozutemiz O, Guler A. Outcomes in the management of gastrocolic fistulas; a single unit's experience. Turk J Gastroenterol. 2008;19(3):152–157.
  4. Marschall J, Bigsby R, Nechala R. Gastrocolic fistulae as a consequence of benign gastric ulcer disease. Can J Gastroenterol. 2003;17(7):441–443.
  5. Huang S, Levine M, Raper S. Gastrocolic fistula with migration of feeding tube into transverse colon as a complication of percutaneous endoscopic gastrostomy. AJR Am J Roentgenol. 2005;184(3):S65e6
  6. Marshall S, Knud-Hansen J. Gastrojejunocolic and gastrocolic fistulas. Ann Surg. 1957;145(5):770e82.
  7. Matsuo S, Eto T, Ohara O, Miyazaki J, Tsunoda T, Kanematsu T. Gastrocolic fistula originating from transverse colon cancer: report of a case and review of the Japanese literature. Surg Today. 1994;24(12):1085e9.
  8. Mathewson C. Preliminary colostomy in the management of gastrocolic and gastrojejunocolic fistulae. Ann Surg. 1941;114(6):1004e10.
  9. Hager J, Gassner I. Gastrocolic fistula in a 7 week old: a rare complication after gastric perforation. J Pediatr Surg. 1994;29(12):1597e8.
  10. Chung J, Lee D, Kim M, Kang J. A case of pancreatico-colo-cutaneous fistula; management guided by endoscopic retrograde cholangio-pancreatography. J Korean Med Sci. 1989;4(1):23e7.
  11. Thyssen E, Weinstock L, Balfe D, Shatz B. Medical treatment of benign gastrocolic fistula. Ann Intern Med. 1993;118(6):433e5.

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Last updated: 2018-06-22 04:24