Gastrocolic Fistula Complicating Transmural Colitis Report of a Case and Review of the Literature
Abstract
A 71-yr-one-time lady presented with a iv-week-history of epigastric pain, feculent airsickness, diarrhoea and weight-loss. On subsequent investigations, she was constitute to accept a complex gastro-cholecysto-colic fistula with no articulate underlying aetiology. The only abnormality both macroscopically and microscopically was ulceration and inflammation in the colon. Nevertheless, this was not pathognomonic of inflammatory bowel disease, and (gastric) acid-induced inflammation is an culling explanation. Herein we present her case, her comprehensive evaluation, her successful surgical management and a review of the relevant literature.
INTRODUCTION
Gastrocolic fistula is a pathological connection betwixt the stomach and colon. These can be associated with a variety of diseases including malignancy of the tum or colon, and beneficial pathologies including peptic ulcer disease and inflammatory bowel disease (IBD). A cholecysto-enteric fistula ordinarily relates to a big gallstone eroding into the gastrointestinal tract, nearly typically via the duodenum. Herein we present a highly unusual case of a fistula involving stomach, colon and gallbladder.
CASE Study
A 71-year-old female presented to the Emergency Department with a 4-week history of worsening epigastric hurting, feculent vomiting and profuse diarrhoea later on eating. At that place was associated weight loss of 10 kg, amounting to 15% of trunk weight. She had no relevant past medical history, such as peptic ulcer disease, colonic disease or biliary symptoms, or prior surgery. She had been on no medication. She had a 50 pack-year smoking history.
Computed tomography (CT) revealed a complex fistulous communication between the distal breadbasket and biliary tree with associated pneumobilia, and between the transverse colon and the distal tum (Fig. 1). No gallstones were seen. Upper and lower gastrointestinal endoscopy was performed, revealing a prepyloric gastric ulceration and fistula (Fig. two), with no obvious gastric pathology, which extended into the colon and a bullheaded cease construction assumed to be the gallbladder. Colonoscopy demonstrated an area of slight narrowing from the hepatic flexure to mid-transverse colon, with macroscopic colitis (Fig. 3). Biopsies were non-specific, with IBD a possibility, but the features were not pathognomonic.
Effigy one
CT abdomen and pelvis demonstrating fistulous communication between distal stomach and transverse colon (red arrow) with pneumobilia.
Figure 1
CT belly and pelvis demonstrating fistulous communication betwixt distal breadbasket and transverse colon (red arrow) with pneumobilia.
Figure 2
Pre-pyloric gastric fistula (red arrow) on upper GI endoscopy.
Figure 2
Pre-pyloric gastric fistula (ruby-red pointer) on upper GI endoscopy.
Effigy 3
Lower GI endoscopy demonstrating ulceration, stenosis and stricturing of the transverse colon.
Figure 3
Lower GI endoscopy demonstrating ulceration, stenosis and stricturing of the transverse colon.
To further characterize, an endoscopic ultrasound demonstrated a fistula between the distal antrum and gallbladder containing air and perhaps some tiny calculi or sediment. The common bile duct was of normal diameter. In that location was no lymphadenopathy and no obvious malignancy seen. Magnetic resonance imaging of the modest bowel outlined the circuitous fistula, and non-specific changes in the colon, only provided no further data regarding aetiology (Fig. 4).
Figure iv
MRI demonstrating gastrocholecystocolic fistula (red pointer).
Figure 4
MRI demonstrating gastrocholecystocolic fistula (red arrow).
The patient was commenced on full parenteral nutrition for 10 days prior to surgery. At laparotomy, the fistulous mass involving the distal stomach, proximal transverse colon and a shrunken gallbladder with no obvious calculi, was dissected en bloc and resected (Fig. five). This involved a correct hemicolectomy, cholecystectomy and distal gastrectomy, with Roux-en-Y reconstruction to the stomach and an ileo-transverse anastomosis.
Figure five
Specimen demonstrating en bloc distal gastrectomy (red arrow), cholecystectomy (shrunken and fibrosed to gastric antrum) and extended correct hemicolectomy (blue arrow).
Figure 5
Specimen demonstrating en bloc distal gastrectomy (red arrow), cholecystectomy (shrunken and fibrosed to gastric antrum) and extended right hemicolectomy (blue pointer).
Histology of the distal tum showed intestinal metaplasia with no dysplasia, tumour or H pylori colonization. Colonic histology showed occasional transmural lymphoid aggregates without definite granulomas suggestive of colonic origin, but definitive histological diagnostic criteria for Crohn'south illness were non met. The gallbladder revealed chronic inflammation, no calculi were evident.
The patient had an unproblematic postoperative class and reported fantabulous health 1 month mail service-operatively.
Give-and-take
This case is highly unusual in that there is both no clear underlying cause, and in that all iii structures were involved. Intraoperatively, the gallbladder was markedly shrunken and fibrosed, only no stone was axiomatic, and the fistulous communication was narrow, unlike the large erosive fistula into the duodenum that may exist associated with gallstone ileus. The common bile duct moreover was normal, with no evidence of Mirizzi syndrome. From the gastric side, the fistula was punched out cleanly with no concerning features. The chief focus on a possible source was the colon, with interesting endoscopic features of macroscopic inflammation starting at the fistulous site and extending ~15 cm distally in the transverse colon. Histological findings however, were inconclusive and not diagnostic of IBD. If not a primary colonic aetiology, another possibility is that gastric acid entering the colon via the fistula caused this non-specific endoscopic and histologic issue.
Fistulae between the breadbasket and colon, and between the gallbladder and enteric structures, may occur in the context of Crohn'south disease, peptic ulcer disease, malignancy of the stomach, colon or gallbladder, following radiation therapy, medications such as non-steroidal anti-inflammatory drugs, aspirin and steroids, or post-operatively. Patients typically complain of abdominal pain, nausea and airsickness, diarrhoea, halitosis and vomiting, and rarely gastrointestinal bleeding [1]. Diagnosis of gastrocolic fistula tin be confirmed with barium enema, which has a specificity of 95%. Endoscopy may miss pocket-size, narrow fistulae located in gastric or colonic folds [two]. CT scan with intravenous and oral dissimilarity is also valuable to confirm the diagnosis, delineate the tract, investigate the primary pathology and for preoperative planning [3, 4]. Management should be multidisciplinary and tailored to each individual patient.
At that place is no previous straight comparable case published to our knowledge. Although ~50% of Crohn'due south patients volition develop some grade of fistula in their lifetime, gastrocolic fistulae are rare. A contempo case series reported 28 examples of gastrocolic fistulas secondary to Crohn'southward disease, with fistulae taking years or fifty-fifty decades to develop [5]. There have been three cases of complex fistulae involving the gallbladder, stomach and colon reported [6–8], however, these cases originated in the gallbladder in dissimilarity to our example where this is highly improbable. Park et al. reported a 67-year-one-time female person patient who presented with haematemesis, and underwent endoscopy and clipping of a Dieulafoy lesion. On follow-up endoscopy, a cholecystogastric fistula was discovered and later at surgery a circuitous cholecysto-gastro-colic fistula identified and resected [6]. Hakim et al. describes a circuitous cholecysto-gastro-colic fistula, which was discovered intraoperatively during hepatic abscess resection from complications of gallbladder disease. The fistula was resected en bloc [seven].
In conclusion, in this example, presenting with classical symptoms and signs of gastro-colic fistula, merely where investigations revealed a fistula into her gallbladder in addition, all-encompassing work up revealed no articulate aetiology. Notwithstanding, surgery was successful and her clinical result excellent. Follow upwards will include continued gastrointestinal surveillance for IBD.
PATIENT CONSENT
Informed patient consent was obtained for the publication of case details and associated imaging.
Author CONTRIBUTIONS
Dr Shane Irwin: Atomic number 82 author, article conception and initial drafting. Final approval and understanding to be accountable for all aspects of the work. Mr Noel Edward Donlon: Contribution to article content, disquisitional draft revision, final approval and agreement to exist answerable for all aspects of the piece of work. Ms Helen Mohan: Contribution to article conception, disquisitional draft revision, terminal blessing and agreement to be accountable for all aspects of the work. Prof. John 5. Reynolds: Contribution to article conception, critical draft revision, final blessing and agreement to be accountable for all aspects of the work.
CONFLICTS OF INTEREST
None alleged.
FUNDING
No funding was received by the authors of this case report.
Dr Shane Irwin: Lead author, article conception and initial drafting. Final approving and agreement to be accountable for all aspects of the work. Mr Noel Edward Donlon: Contribution to article content, critical typhoon revision, final approving and understanding to exist accountable for all aspects of the work. Ms Helen Mohan: Contribution to article conception, critical draft revision, concluding blessing and agreement to be accountable for all aspects of the work. Prof. John V. Reynolds: Contribution to article formulation, disquisitional typhoon revision, final approving and understanding to be accountable for all aspects of the piece of work.
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