Look both ways: gastrojejunocolic fistula masquerading as irritable bowel disease

A 45-year-old patient was admitted to our department because of a history of diarrhea with red blood (hematochezia) and marked weight loss; all the symptoms had started about 6 months earlier. Physical examination revealed just a pale, emaciated patient with a surgical abdominal scar. The patient had undergone surgery for peptic ulcer disease 4 years previously. Because the current symptoms suggested inflammatory or malignant disease of the colon, the first imaging procedure performed was colonoscopy, during which the endoscope was able to pass abnormally, in the region of transverse colon, into another gut structure where the mucosal folds resembled those of the stomach. The passage was through a big fistula with a 3-cm ulcer with signs of recent bleeding ([Fig. 1], [2]). Upper gastrointestinal endoscopy was further performed and visualized the partially resected stomach with a Billroth II gastroenteroanastomosis. Above the anastomosis, a big fistula was visible leading to the transverse colon ([Fig. 3], [Video 1]). A barium study of the stomach was also performed, confirming the fistula with early presence of contrast inside the colon ([Fig. 4]). The patient was referred on to the surgery department where he was treated successfully, with conversion into a Roux-en-Y anastomosis. The further course was favorable, with complete recovery of the patient and no symptoms at 1-year follow-up.

Fig. 1 Colonoscopy showing the opening of the fistula (transverse colon), with a chronic peptic ulcer at this level causing the diarrhea and hematochezia.

Fig. 2 Colonoscopy of the transverse colon with passage of the colonoscope through the fistula: entrance into the stomach (A) and jejunum (B).

Fig. 3 Upper gastrointestinal endoscopy revealed the entrances into the duodenum (afferent loop), jejunum (efferent loop), and transverse colon (fistula tract).

Fig. 4 Barium study of the stomach showed early passage of the contrast into the colon (visible horizontal air-fluid levels).

Although barium enema is still considered the diagnostic investigation of choice for this condition, with a sensitivity of 95 – 100 % [1] [2], in the present case the confusion with irritable bowel disease or even colorectal cancer dictated colonoscopy as first diagnostic procedure. Gastrojejunocolic fistula, although rare, is seen occasionally in current practice as a result of past gastric surgery [3]. However, such fistulas can also result from peptic ulcer disease, neoplasm, Crohn’s disease, and infections [4]. Both gastroscopy and colonoscopy can be performed successfully in these patients, in order to establish the diagnosis and to define the precise location of the fistula before corrective surgery is carried out.

Video 1 Upper gastrointestinal endoscopy reveals the entrances into the duodenum (afferent loop), jejunum (efferent loop), and transverse colon (fistula tract).

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References

• 1 Chung D P, Li R S, Leong H T. Diagnosis and current management of gastrojejunocolic fistula.  Hong Kong Med J. 2001;  7 439-441
• 2 Ohta M, Konno H, Tanaka T. et al . Gastrojejunocolic fistula after gastrectomy with Billroth II reconstruction: report of a case.  Surg Today. 2002;  32 367-370
• 3 Herbella F A, Del G rande, Beaton H L. Surgical images: soft tissue. Postgastrectomy benign gastrojejunocolic fistula.  Can J Surg. 2007;  50 397-398
• 4 Malayil V T, Tony J, Harish K. et al . Simultaneous gastroscopy and colonoscopy for the diagnosis of gastrojejunocolic fistula.  Gastrointest Endosc. 2007;  66 597-598