Gastrocolic Fistulae in Benign Peptic Ulcer Disease G. KRISHNA KUMAR, M.D., F.R.C.P.(C), F.A.C.G.,* MOHAMMED A. RAZZAQUE, M.D.,t VENKATA G. NAIDU, M.D.,4 EDMUND M. BARBOUR, M.D.§
Occurrence of gastroenteric fistulae in non-surgically treated From the Wayne State University School of Medicine, peptic ulcer disease is rare as suggested by only 26 cases published and the Detroit General Hospital, in the literature so far. We had the opportunity to care for 3 Detroit, Michigan patients with this problem in a period of one year. At our institution, a search of the medical records dating back to 1955 yielded one additional case. Most of our patients had a history of salicylate or corticosteroid intake. We present here the details of Case Reports these cases and discuss the possible role of the location of the ulcer Case 1. V.S., a 48-year-old Caucasian woman, was admitted to Detroit and ulcerogenic anti-inflammatory drug ingestion in the causation General Hospital on 4-25-73 with complaints of abdominal pain, of gastroenteric fistula. We believe the incidence of this uncommon entity may rise significantly with the more common use of vomiting and weight loss of 4 months duration. She had been having pain in the epigastric region and left paraumbilical area for at least one year salicylates and corticosteroids.
G ASTROCOLIC FISTULA is a rare complication of
%_J~nonsurgically treated benign peptic ulcer disease. A recent review of the English literature revealed only 24 documented case reports of this entity.10 A search of Mayo Clinic records by Smith and Claggett12 yielded only one patient with this entity. A review of all the surgical records at Scott and White Clinic and all its affiliated hospitals by Broder2 revealed 2 similar cases. Three patients with gastroenteric fistulae were seen at Wayne State University, School of Medicine affiliated hospitals during the years 1973-74, and a review of the records at Detroit General Hospital between the periods 1952-1972 yielded one additional case. We are reporting these four patients to call attention to this very rare but important complication of benign peptic ulcer disease. Submitted for publication February 7, 1976. * Assistant Professor of Medicine, Wayne State University School of Medicine and the Detroit General Hospital. t Instructor of Medicine, Wayne State University School of Medicine and the Detroit General Hospital. t Fellow in Intemral Medicine, Detroit General Hospital. § Instructor of Medicine, Wayne State University School of Medicine and the Harper Hospital. All correspondence to: Dr. G. Krishna Kumar, Assistant Professor of Medicine, Wayne State University School of Medicine, 540 East Canfield Avenue, Detroit, Michigan 48201.
and daily vomiting one-half to one hour following meals for 5 months. She also related the history of weight loss (35 lbs in 4 months). She denied any diarrhea, hematemesis or melena. She had been taking aspirin every day for headaches and abdominal pain for over 6 months. She denied excessive alcohol intake or smoking. There was no past history of peptic ulcer disease. The physical findings on admission revealed an undernourished, moderately pale patient, in no acute distress. Her vital signs were within normal limits. The lung fields were clear to percussion and auscultation. The cardiovascular system was unremarkable. Abdominal examination revealed tenderness over the left paraumbilical area with a questionable mass in the epigastrium. No hepatosplenomegaly was found. Rectal examination revealed no mass or guiaic positive stool. Laboratory findings included initial hemoglobin 7.2 gm/100 ml, WBC 10,000 per ml with normal differential, McV 79 mm3, McH 25.8, McHc 32. 1%. Multiple screening test showed alkaline phosphatase 140 IU/ (normal 40-80 IU). The remainder of the screening tests which included calcium, total protein, albumin, globulin, cholesterol, SGOT, LDH, total bilirubin, blood urea, nitrogen and creatinine were all within normal limits. The serum amylase level was 51 units and fasting blood sugar was 120 mg/100 ml, B.S.P. retention was 1% at 45 minutes. Serum sodium was 132 mEq/l, potassium 3.4 mEq/L and chloride 93 mEq/L. The urinalysis revealed 8-10 WBC/HPF. UGI was interpreted as having a nodular mass along the greater curvature protruding into the stomach cavity. The mass had a possible ulceration on the top. A barium enema was normal. A gastroduodenoscopy was performed. The examiner noted that duodenal bile content was regurgitating into the stomach through a mucosal mass and the normal pylorus was visualized 4 cm distal to this area. The mass was biopsied and this revealed no malignancy. A surgical exploration of the abdomen revealed a mass along the greater curvature of the stomach with a fistula between the stomach, jejunum and transverse colon. The surgical procedure included subtotal gastrectomy with gastrojejunostomy,
236
Vol. 184 * No. 2
GASTROCOLIC FISTULAE
:.-' !:';
E'
* A
W w
I f
£
_
237
Laboratory findings revealed the following: urinalysis was normal, white blood count was 12,605 with a differential count of polymorph 63 lymphocytes 28, monocytes 6% and basophils 3%. The hemoglobulin was 12.6 gm/100 ml. Serum electrolytes were normal. Multiple blood cultures did not grow any organisms. Blood urea nitrogen was 19 mg/ 100 ml, serum prothrombin time was 13.3 seconds with a control of 14 seconds. L.E. prep was negative. A chest x-ray was normal. Stools for occult blood were 4+ positive persistently. Gastric content was positive for occult blood. Serum calcium was 7.7 gm/100 ml. Phosphorous of 5 mg/100 ml. A flat film of the abdomen showed 'non-specific gas pattern. An upper gastrointestinal series revealed a penetrating ulcer along the greater curvature of the stomach with no evidence of fistulous tract. A barium enema demonstrated the fistulous tract between the stomach and colon in the region of the splenic flexure. An exploratory laparotomy with wedge resection of the stomach and colon was performed. Case 3. T.A., a 51-year-old Caucasian man, was admitted to Harper Hospital on February 20, 1973, with complaints of severe abdominal pain associated with vomiting of 6 weeks duration. The description of the patient's vomitus was suggestive of fecal matter. The patient denied any history of peptic discomfort or gastrointestinal malignancy. The patient admitted to aspirin and prednisolone intake for three years prior to admission for "rheumatoid arthritis." The amount of prednisolone on the average was 20 mg per day. Aspirin intake varied between 2 to 3 The patient had lost 10 pounds prior to admission. gnm/day. The physical examination was initially unremarkable. The patient appeared fairly well nourished but somewhat pale. Abdominal examination revealed minimal tenderness in the epigastrium with no palpable
FIG. 1. (Case 1). Upper gastrointestinal series showing a filling defect (arrow shows site of fistula).
segmental resection of the transverse colon and part of the small bowel. Histological examination confirmed the existence of a chronic benign ulcer along the greater curvature of the stomach with fistulous tract. Case 2. J.A., a 12-year-old Caucasian girl, was admitted to Detroit General Hospital with bloody diarrhea and vague upper abdominal pain in 1954. Six months prior to admission, she was diagnosed as having dermatomyositis. She was treated with ACTH for 4 to 5 weeks. During the course of treatment with ACTH, she had vague upper abdominal pain at varying times. Prior to the current hospital admission, she was seen in the clinic with exacerbation of symptoms of dermatomyosis and she was placed on ACTH therapy (60 units daily) which was tapered gradually to 40 units per day on 9-2-54. She was seen with continued abdominal pain which was relieved at times by eggnog ingestion. She was also constipated for two days prior to the episode of bloody diarrhea. Physical examination on admission revealed her blood pressure to be 130/80, and the oral temperature 39O. Examination of the abdomen revealed generalized muscle guarding and diffuse tenderness. No organs or masses could be palpated. Her lungs were clear to percussion and auscultation. Examination of the cardiovascular system was withinl normal limits. Examination of the skin showed generalized rashed and superficial scales.
FIG. 2. (Case 3). Uppergastrointestinal series showing gastrocolic fistula (arrow shows fistulous tract).I
238
KUMAR A]ND OTHERS
Ann. Surg. * August 1976
healing. The ulcer appeared benign endoscopically and was benign cytologically. The patient was placed on intensive antacid therapy and the peptic symptoms disappeared within a few weeks. Eight weeks prior to admission, the patient abruptly started having diarrhea 4 to 5 times a day, occurring immediately after eating. The patient consulted a physician and was placed on Lomotil which did not stop the diarrhea and in the period of 6 weeks, the patient lost 8 pounds. The patient was hospitalized and a barium enema was performed on October 12, 1973, revealing a gastrocolic fistula in the area ofthe previous gastric ulcer. An upper gastrointestinal series done after hospitalization revealed possible filling defect in the region of the greater curvature of the stomach with fistulous tract between the stomach and the transverse colon. The patient underwent surgery and a resection of the fistulous tract, including the colon and part of the stomach was accomplished. The pathological examination confirmed the existence of multiple benign gastric ulcers in the antrum and gastrocolic fistula secondary to perforated benign gastric ulcer. The patient had an uneventful postoperative course and was discharged home on October 17, 1973.
FIG. 3. (Case 4). Upper gastrointestinal series revealed barium flowing into the colon directly from the stomach (arrow shows the greater curvature antral deformity which was the site of the fistula). masses. Spleen, liver and kidneys were normal. Bowel sounds were normal. Rectal examination was within normal limits. Laboratory examination revealed a hemoglobin of 12.1 gm/100 ml, normal white cell count and differential 6,800, neutrophil 78%, lymphocytes 20o and monocytes 2%; urinalysis was normal; SMA12 was normal. Upper gastrointestinal series suggested a possible gastrocolic fistula and this was confirmed by a barium enema which revealed a fistulous tract between the stomach and the colon. Gastroscopy revealed an ulcer in the mid-stomach of the greater curvature aspect which endoscopically appeared to be benign. Cytology and biopsies were obtained and these did not reveal any malignancy. A colonoscopy also confirmed the possibility of fistulous tract at the mid-transverse colon but no attempt was made to pass the colonscopy through the fistulous tract. Cytological and biopsy specimen failed to reveal any evidence of malignancy. The patient was subjected to an exploratory laparotomy in March, 1973, at which time a gastrocolic fistula was demonstrated. A segmental colonic resection with hemigastrectomy and an end to end anastomosis of the colon was done. The pathologic examination confirmed the preoperative impression of benign gastric ulcer with gastrocolic fistula. The patient had an uneventful postoperative course. Case 4. F.F., a 40-year-old woman, was admitted to William Beaumont Hospital on October 14, 1973, with a chief complaint of diarrhea of 8 weeks duration. The patient gave a history of "stomach ulcer" which was diagnosed in March, 1973 at which time a gastroscopy revealed an ulcer in the greater curvature aspect of the antrum which appeared to be
Discussion Peptic ulcer disease is a rare cause of gastrocolic fistulae. The usual causes of gastrocolic fistula are cancer of the colon and stomach,3 post-traumatic,11 postsurgical,6 carcinoid tumor,7 ulcerative colitis,l perforated colonic diverticulum and intra-abdominal abscesses resulting in fistula.' A complete review of the literature10 revealed 26 patients with gastrocolic fistula resulting from benign peptid ulcer (Table 1) to which our 4 cases were added bringing the total number to 30. Peter and Benfield,10 in 1972 reviewed 24 cases, including 2 of their own, and over one-third of them had a history of steroid and/or aspirin intake. Two of their patients also had been taking excessive aspirin prior to developing gastrocolic fistula. Hoffman reported a case of gastrocolic fistula in 1966 with a review of patients who had developed this complication while on cortisone intake.5 Frieberger and co-workers1 found an incidence of peptic ulcer to be 31% in a group of patients who were taking cortisone for various disorders. They also found gastric ulcers 6 times more common than duodenal ulcer in this group of patients on cortisone. All but two of the gastric ulcers were in the antrum and 8 of 28 ulcers in the antrum were in the greater curvature aspect. Patients on steroids seen to develop gastric ulcers more commonly in the greater curvature aspect. Interestingly, the three patients in our series who had been taking cortisone and aspirin had the ulcer in the greater curvature aspect which could be an ideal anatomic position for penetrating ulcer to lead to gastrocolic fistula. Even in the fourth patient who had not been taking any ulcerogenic drugs, the ulcer was located in the greater curvature aspect. The minimal inflammatory reaction noted around the ulcer in our patients were again noted by other authors who made similar observations. Since both aspirin and corticosteroids are antiinflammatory agents, probably they mask the symptomatology of the ulcer and also decreases the inflammatorv reaction associated with penetrating ulcer, thereby, leading to silent penetration into the adjacent
239
GASTROCOLIC FISTULAE
Vol. 184 * No. 2
TABLE 1. Chronological Summary of Benign Gastroenteric Fistula From The English Literature
Author Firth Wilkie
Bailey & Knoll Pein Briggs & Boswell
Age & Sex 51, M 32, M ?, F 5 weeks, M 58, M
Duration
Ulcerogenic Drugs
Fistula
8 mon 10 yr ? ? 6 mon
None None None
Gastrocolic
None
None
Gastrocolic Gastrocolic Gastrocolic Gastrocolit &
gastroduodenal
Operation Laparotomy
2-stage Procedure ? Fistula excision 1-stage Procedure
Bosien & Tyson Bachman & Rogers Gray Davey Swartz et al.
45, M
6 yr
Steroids
Gastrocolic
1-stage Procedure
33, 35, 72, 54,
1 week 20 yr 24 yr 4 mon
Steroids None None Steroids
Gastrocolic Gastrocolic Gastrojejunal Gastrocolic &
Fistula excision 3-stage 1-stage 1-stage
Deshpande
56, F
2 yr
None
Gastrocolic &
F F F M
Smith & Clagett Lazar13 Hoffman Ganji et al. Agus & Estrin Stems & Bird Dotson & Shu'ayb Fishman et al. Blumen" Ger et al. Friedman et al.
54, 54, 49, 65, 69, 29, 52, 64, 52, 58, 44,
M F F M M F F M F F F
3 yr 3 weeks ? mon 2 weeks 6 mon 5 yr 2 yr ? mon 2 mon 5 mon 32 yr
Peter & Benfield Peter & Benfield Broders Broders Kumar et al.
46, 52, 43, 73, 48, 12, 51,
F F M M M F M
5 yr 9 yr 4 mon 5 weeks 4 mon 4-5 weeks 6 weeks
40, F *
8 weeks
Aspirin None Steroids None Steroids None None None None Steroids Narcotic Addiction Aspirin Aspirin None None Aspirin ACTH Aspirin & Prednisolone None
gastrojejunal
1-stage
gastrojejunal
Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic
Gastrojejunocolic Gastrocolic
1-stage 1-stage 1-stage 2-stage 1-stage 1-stage
1-stage 1-stage 1-stage
Gastrojejunocolic
1-stage
Gastrojejunal Gastrocolic
1-stage 1-stage 1-stage 1-stage 1-stage 1-stage
Gastrocolic Gastrocolic Gastrojejunocolic Gastrocolic Gastrocolic Gastrocolic
1-stage
1-stage
1-stage excision of fistula and involved adjacent organs; 2-stage, colostomy, then resection of fistula and involved adjacent organs; 3-stage
colostomy, resection of fistula and involved adjacent organ, then colostomy closure; fistula excision, excision of fistula and bowel closure only.
viscus. Although, we are not certain about the exact The diagnosis was accomplished by barium enema, mechanism, it is possible that the anti-inflammatory upper gastrointestinal and small bowel series; success rate properties of these agents may have something to do with of demonstrating this lesion was highest with barium the formation of fistula in this group of patients. enema. In one series, diagnostic accuracy of 95% was In our group of 4 patients, 3 had a history of significant achieved by barium enema, whereas, only 18-27% were ulcerogenic drug intake. All of our patients denied any diagnosed by oral barium swallow.13 Endoscopy cannot acute onset of symptoms suggestive of penetration and/or be relied upon as primary diagnostic tool in this entity, perforation into the adjacent viscus. The usual age of since one can miss the communication unless the fistulous occurence is in the fourth or fifth decade, although this orifice is big enough to be easily visualized. If the fistulae condition has been described in infants.9 are small and narrow, this can be hidden between the The symptomatology is fairly typical in all patients gastric folds and can be easily missed. Once the diagnosis except in one. Symptoms consist of vague peptic has been suspected by the barium enema, endoscopy symptoms, fecal vomiting and fecal eructation. Duration serves as a useful purpose of actually visualizing the fistula of symptoms ranged from one month to four years. In and obtaining cytological and biopsy materials to clarify some patients, abdominal mass was the initial sign. Loss the nature of this communication. of weight was noted in most of these patients and in one The therapy of this entity is primary excision and series, as high as 80%o ofthe patients had loss of weight and anastomosis.10 In the past, staged operations have been 30%o of them had fecal eructation.8 Anemia and malnutri- recommended with initial colostomy, but if the disease is tion were associated findings as noted in our group of not active, the primary excision may be accomplished patients. without any significant increase in morbidity and mortal-
240 ity. If active inflammatory
KUMAR AND OTHERS
with peritonitis is present, a more conservative approach such as, staged procedure with initial colostomy may be indicated. processes
References 1. Barter, K. W., Jr., Waush, J. and Priestly, J. T.: Operation in One-Stage for Gastrojejunocolic Fistula. Surg. Clin. North Am., 42:1443, 1963. 2. Broders, W. C.: Benign Gastrocolic Fistula. Report of Two Cases. Am. Surg., 39:342-3, 1973. 3. Dickson, W. J.: Gastrolic Fistula. Canad. Med. Assoc. J., 18:272, 1928. 4. Frieberger, R. H., Kammerev, W. H. and Rijelis, A. L.: Peptic Ulcers in Rheumatoid Patients Receiving Corticosteroid Therapy. Radiology, 71:542-547, 1958. 5. Hoffman, R. D.: Gastrocolic Fistula and Gastric Ulcer with Prolonged Glucocorticoid Therapy. JAMA, 195:6:493, 1966.
Ann. Surg.
August 1976
6. Lowden, 0. B. E.: Gastrojejunocolic Fistula. Br. J. Surg., 41:113, 1963. 7. Lynch, R. C. and Boese, J. L.: Carcinoic Tumor of Transverse Colon Complicated by Gastrocolic Fistula. Surgery, 38:3:600, 1955. 8. Marshall, S. F. and Kund, H. J.: Gastrojejunocolic and Gastrocolic Fistula. Ann. Surg., 145:770, 1957. 9. Pein, N. K.: Neonatal Gastrocolic Fistula. Lancet, 2:53, 1948. 10. Peter, M. and Benfield, J.: Benign Gastroenteric Fistula and Aspirin Abuse. Arch. Surg., 104:787, 1972. 11. Schweitzer, R. J. and Osborne, M. P.: Gastrocolic Fistula Complicating Carcinoma: Report of a Case due to Carcinoma of Colon with Successful Resection. Am. J. Surg., 85:775, 1953. 12. Smith, D. L. and Claggett, 0. T.: Gastrocolic Fistula Secondary to Benign Ulcer. Report of a Case. Surgery, 58:634, 1965. 13. Theony, R. H., Hodson, J. R. and Scudamore, H. H.: Roentgenologic Diagnosis of Gastrocolic and Gastrojejunocolic Fistulas. Am. J. Roentgen. Radium Ther. Nucl. Med., 38:876, 1960.
Occurrence of gastroenteric fistulae in non-surgically treated From the Wayne State University School of Medicine, peptic ulcer disease is rare as suggested by only 26 cases published and the Detroit General Hospital, in the literature so far. We had the opportunity to care for 3 Detroit, Michigan patients with this problem in a period of one year. At our institution, a search of the medical records dating back to 1955 yielded one additional case. Most of our patients had a history of salicylate or corticosteroid intake. We present here the details of Case Reports these cases and discuss the possible role of the location of the ulcer Case 1. V.S., a 48-year-old Caucasian woman, was admitted to Detroit and ulcerogenic anti-inflammatory drug ingestion in the causation General Hospital on 4-25-73 with complaints of abdominal pain, of gastroenteric fistula. We believe the incidence of this uncommon entity may rise significantly with the more common use of vomiting and weight loss of 4 months duration. She had been having pain in the epigastric region and left paraumbilical area for at least one year salicylates and corticosteroids.
G ASTROCOLIC FISTULA is a rare complication of
%_J~nonsurgically treated benign peptic ulcer disease. A recent review of the English literature revealed only 24 documented case reports of this entity.10 A search of Mayo Clinic records by Smith and Claggett12 yielded only one patient with this entity. A review of all the surgical records at Scott and White Clinic and all its affiliated hospitals by Broder2 revealed 2 similar cases. Three patients with gastroenteric fistulae were seen at Wayne State University, School of Medicine affiliated hospitals during the years 1973-74, and a review of the records at Detroit General Hospital between the periods 1952-1972 yielded one additional case. We are reporting these four patients to call attention to this very rare but important complication of benign peptic ulcer disease. Submitted for publication February 7, 1976. * Assistant Professor of Medicine, Wayne State University School of Medicine and the Detroit General Hospital. t Instructor of Medicine, Wayne State University School of Medicine and the Detroit General Hospital. t Fellow in Intemral Medicine, Detroit General Hospital. § Instructor of Medicine, Wayne State University School of Medicine and the Harper Hospital. All correspondence to: Dr. G. Krishna Kumar, Assistant Professor of Medicine, Wayne State University School of Medicine, 540 East Canfield Avenue, Detroit, Michigan 48201.
and daily vomiting one-half to one hour following meals for 5 months. She also related the history of weight loss (35 lbs in 4 months). She denied any diarrhea, hematemesis or melena. She had been taking aspirin every day for headaches and abdominal pain for over 6 months. She denied excessive alcohol intake or smoking. There was no past history of peptic ulcer disease. The physical findings on admission revealed an undernourished, moderately pale patient, in no acute distress. Her vital signs were within normal limits. The lung fields were clear to percussion and auscultation. The cardiovascular system was unremarkable. Abdominal examination revealed tenderness over the left paraumbilical area with a questionable mass in the epigastrium. No hepatosplenomegaly was found. Rectal examination revealed no mass or guiaic positive stool. Laboratory findings included initial hemoglobin 7.2 gm/100 ml, WBC 10,000 per ml with normal differential, McV 79 mm3, McH 25.8, McHc 32. 1%. Multiple screening test showed alkaline phosphatase 140 IU/ (normal 40-80 IU). The remainder of the screening tests which included calcium, total protein, albumin, globulin, cholesterol, SGOT, LDH, total bilirubin, blood urea, nitrogen and creatinine were all within normal limits. The serum amylase level was 51 units and fasting blood sugar was 120 mg/100 ml, B.S.P. retention was 1% at 45 minutes. Serum sodium was 132 mEq/l, potassium 3.4 mEq/L and chloride 93 mEq/L. The urinalysis revealed 8-10 WBC/HPF. UGI was interpreted as having a nodular mass along the greater curvature protruding into the stomach cavity. The mass had a possible ulceration on the top. A barium enema was normal. A gastroduodenoscopy was performed. The examiner noted that duodenal bile content was regurgitating into the stomach through a mucosal mass and the normal pylorus was visualized 4 cm distal to this area. The mass was biopsied and this revealed no malignancy. A surgical exploration of the abdomen revealed a mass along the greater curvature of the stomach with a fistula between the stomach, jejunum and transverse colon. The surgical procedure included subtotal gastrectomy with gastrojejunostomy,
236
Vol. 184 * No. 2
GASTROCOLIC FISTULAE
:.-' !:';
E'
* A
W w
I f
£
_
237
Laboratory findings revealed the following: urinalysis was normal, white blood count was 12,605 with a differential count of polymorph 63 lymphocytes 28, monocytes 6% and basophils 3%. The hemoglobulin was 12.6 gm/100 ml. Serum electrolytes were normal. Multiple blood cultures did not grow any organisms. Blood urea nitrogen was 19 mg/ 100 ml, serum prothrombin time was 13.3 seconds with a control of 14 seconds. L.E. prep was negative. A chest x-ray was normal. Stools for occult blood were 4+ positive persistently. Gastric content was positive for occult blood. Serum calcium was 7.7 gm/100 ml. Phosphorous of 5 mg/100 ml. A flat film of the abdomen showed 'non-specific gas pattern. An upper gastrointestinal series revealed a penetrating ulcer along the greater curvature of the stomach with no evidence of fistulous tract. A barium enema demonstrated the fistulous tract between the stomach and colon in the region of the splenic flexure. An exploratory laparotomy with wedge resection of the stomach and colon was performed. Case 3. T.A., a 51-year-old Caucasian man, was admitted to Harper Hospital on February 20, 1973, with complaints of severe abdominal pain associated with vomiting of 6 weeks duration. The description of the patient's vomitus was suggestive of fecal matter. The patient denied any history of peptic discomfort or gastrointestinal malignancy. The patient admitted to aspirin and prednisolone intake for three years prior to admission for "rheumatoid arthritis." The amount of prednisolone on the average was 20 mg per day. Aspirin intake varied between 2 to 3 The patient had lost 10 pounds prior to admission. gnm/day. The physical examination was initially unremarkable. The patient appeared fairly well nourished but somewhat pale. Abdominal examination revealed minimal tenderness in the epigastrium with no palpable
FIG. 1. (Case 1). Upper gastrointestinal series showing a filling defect (arrow shows site of fistula).
segmental resection of the transverse colon and part of the small bowel. Histological examination confirmed the existence of a chronic benign ulcer along the greater curvature of the stomach with fistulous tract. Case 2. J.A., a 12-year-old Caucasian girl, was admitted to Detroit General Hospital with bloody diarrhea and vague upper abdominal pain in 1954. Six months prior to admission, she was diagnosed as having dermatomyositis. She was treated with ACTH for 4 to 5 weeks. During the course of treatment with ACTH, she had vague upper abdominal pain at varying times. Prior to the current hospital admission, she was seen in the clinic with exacerbation of symptoms of dermatomyosis and she was placed on ACTH therapy (60 units daily) which was tapered gradually to 40 units per day on 9-2-54. She was seen with continued abdominal pain which was relieved at times by eggnog ingestion. She was also constipated for two days prior to the episode of bloody diarrhea. Physical examination on admission revealed her blood pressure to be 130/80, and the oral temperature 39O. Examination of the abdomen revealed generalized muscle guarding and diffuse tenderness. No organs or masses could be palpated. Her lungs were clear to percussion and auscultation. Examination of the cardiovascular system was withinl normal limits. Examination of the skin showed generalized rashed and superficial scales.
FIG. 2. (Case 3). Uppergastrointestinal series showing gastrocolic fistula (arrow shows fistulous tract).I
238
KUMAR A]ND OTHERS
Ann. Surg. * August 1976
healing. The ulcer appeared benign endoscopically and was benign cytologically. The patient was placed on intensive antacid therapy and the peptic symptoms disappeared within a few weeks. Eight weeks prior to admission, the patient abruptly started having diarrhea 4 to 5 times a day, occurring immediately after eating. The patient consulted a physician and was placed on Lomotil which did not stop the diarrhea and in the period of 6 weeks, the patient lost 8 pounds. The patient was hospitalized and a barium enema was performed on October 12, 1973, revealing a gastrocolic fistula in the area ofthe previous gastric ulcer. An upper gastrointestinal series done after hospitalization revealed possible filling defect in the region of the greater curvature of the stomach with fistulous tract between the stomach and the transverse colon. The patient underwent surgery and a resection of the fistulous tract, including the colon and part of the stomach was accomplished. The pathological examination confirmed the existence of multiple benign gastric ulcers in the antrum and gastrocolic fistula secondary to perforated benign gastric ulcer. The patient had an uneventful postoperative course and was discharged home on October 17, 1973.
FIG. 3. (Case 4). Upper gastrointestinal series revealed barium flowing into the colon directly from the stomach (arrow shows the greater curvature antral deformity which was the site of the fistula). masses. Spleen, liver and kidneys were normal. Bowel sounds were normal. Rectal examination was within normal limits. Laboratory examination revealed a hemoglobin of 12.1 gm/100 ml, normal white cell count and differential 6,800, neutrophil 78%, lymphocytes 20o and monocytes 2%; urinalysis was normal; SMA12 was normal. Upper gastrointestinal series suggested a possible gastrocolic fistula and this was confirmed by a barium enema which revealed a fistulous tract between the stomach and the colon. Gastroscopy revealed an ulcer in the mid-stomach of the greater curvature aspect which endoscopically appeared to be benign. Cytology and biopsies were obtained and these did not reveal any malignancy. A colonoscopy also confirmed the possibility of fistulous tract at the mid-transverse colon but no attempt was made to pass the colonscopy through the fistulous tract. Cytological and biopsy specimen failed to reveal any evidence of malignancy. The patient was subjected to an exploratory laparotomy in March, 1973, at which time a gastrocolic fistula was demonstrated. A segmental colonic resection with hemigastrectomy and an end to end anastomosis of the colon was done. The pathologic examination confirmed the preoperative impression of benign gastric ulcer with gastrocolic fistula. The patient had an uneventful postoperative course. Case 4. F.F., a 40-year-old woman, was admitted to William Beaumont Hospital on October 14, 1973, with a chief complaint of diarrhea of 8 weeks duration. The patient gave a history of "stomach ulcer" which was diagnosed in March, 1973 at which time a gastroscopy revealed an ulcer in the greater curvature aspect of the antrum which appeared to be
Discussion Peptic ulcer disease is a rare cause of gastrocolic fistulae. The usual causes of gastrocolic fistula are cancer of the colon and stomach,3 post-traumatic,11 postsurgical,6 carcinoid tumor,7 ulcerative colitis,l perforated colonic diverticulum and intra-abdominal abscesses resulting in fistula.' A complete review of the literature10 revealed 26 patients with gastrocolic fistula resulting from benign peptid ulcer (Table 1) to which our 4 cases were added bringing the total number to 30. Peter and Benfield,10 in 1972 reviewed 24 cases, including 2 of their own, and over one-third of them had a history of steroid and/or aspirin intake. Two of their patients also had been taking excessive aspirin prior to developing gastrocolic fistula. Hoffman reported a case of gastrocolic fistula in 1966 with a review of patients who had developed this complication while on cortisone intake.5 Frieberger and co-workers1 found an incidence of peptic ulcer to be 31% in a group of patients who were taking cortisone for various disorders. They also found gastric ulcers 6 times more common than duodenal ulcer in this group of patients on cortisone. All but two of the gastric ulcers were in the antrum and 8 of 28 ulcers in the antrum were in the greater curvature aspect. Patients on steroids seen to develop gastric ulcers more commonly in the greater curvature aspect. Interestingly, the three patients in our series who had been taking cortisone and aspirin had the ulcer in the greater curvature aspect which could be an ideal anatomic position for penetrating ulcer to lead to gastrocolic fistula. Even in the fourth patient who had not been taking any ulcerogenic drugs, the ulcer was located in the greater curvature aspect. The minimal inflammatory reaction noted around the ulcer in our patients were again noted by other authors who made similar observations. Since both aspirin and corticosteroids are antiinflammatory agents, probably they mask the symptomatology of the ulcer and also decreases the inflammatorv reaction associated with penetrating ulcer, thereby, leading to silent penetration into the adjacent
239
GASTROCOLIC FISTULAE
Vol. 184 * No. 2
TABLE 1. Chronological Summary of Benign Gastroenteric Fistula From The English Literature
Author Firth Wilkie
Bailey & Knoll Pein Briggs & Boswell
Age & Sex 51, M 32, M ?, F 5 weeks, M 58, M
Duration
Ulcerogenic Drugs
Fistula
8 mon 10 yr ? ? 6 mon
None None None
Gastrocolic
None
None
Gastrocolic Gastrocolic Gastrocolic Gastrocolit &
gastroduodenal
Operation Laparotomy
2-stage Procedure ? Fistula excision 1-stage Procedure
Bosien & Tyson Bachman & Rogers Gray Davey Swartz et al.
45, M
6 yr
Steroids
Gastrocolic
1-stage Procedure
33, 35, 72, 54,
1 week 20 yr 24 yr 4 mon
Steroids None None Steroids
Gastrocolic Gastrocolic Gastrojejunal Gastrocolic &
Fistula excision 3-stage 1-stage 1-stage
Deshpande
56, F
2 yr
None
Gastrocolic &
F F F M
Smith & Clagett Lazar13 Hoffman Ganji et al. Agus & Estrin Stems & Bird Dotson & Shu'ayb Fishman et al. Blumen" Ger et al. Friedman et al.
54, 54, 49, 65, 69, 29, 52, 64, 52, 58, 44,
M F F M M F F M F F F
3 yr 3 weeks ? mon 2 weeks 6 mon 5 yr 2 yr ? mon 2 mon 5 mon 32 yr
Peter & Benfield Peter & Benfield Broders Broders Kumar et al.
46, 52, 43, 73, 48, 12, 51,
F F M M M F M
5 yr 9 yr 4 mon 5 weeks 4 mon 4-5 weeks 6 weeks
40, F *
8 weeks
Aspirin None Steroids None Steroids None None None None Steroids Narcotic Addiction Aspirin Aspirin None None Aspirin ACTH Aspirin & Prednisolone None
gastrojejunal
1-stage
gastrojejunal
Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic Gastrocolic
Gastrojejunocolic Gastrocolic
1-stage 1-stage 1-stage 2-stage 1-stage 1-stage
1-stage 1-stage 1-stage
Gastrojejunocolic
1-stage
Gastrojejunal Gastrocolic
1-stage 1-stage 1-stage 1-stage 1-stage 1-stage
Gastrocolic Gastrocolic Gastrojejunocolic Gastrocolic Gastrocolic Gastrocolic
1-stage
1-stage
1-stage excision of fistula and involved adjacent organs; 2-stage, colostomy, then resection of fistula and involved adjacent organs; 3-stage
colostomy, resection of fistula and involved adjacent organ, then colostomy closure; fistula excision, excision of fistula and bowel closure only.
viscus. Although, we are not certain about the exact The diagnosis was accomplished by barium enema, mechanism, it is possible that the anti-inflammatory upper gastrointestinal and small bowel series; success rate properties of these agents may have something to do with of demonstrating this lesion was highest with barium the formation of fistula in this group of patients. enema. In one series, diagnostic accuracy of 95% was In our group of 4 patients, 3 had a history of significant achieved by barium enema, whereas, only 18-27% were ulcerogenic drug intake. All of our patients denied any diagnosed by oral barium swallow.13 Endoscopy cannot acute onset of symptoms suggestive of penetration and/or be relied upon as primary diagnostic tool in this entity, perforation into the adjacent viscus. The usual age of since one can miss the communication unless the fistulous occurence is in the fourth or fifth decade, although this orifice is big enough to be easily visualized. If the fistulae condition has been described in infants.9 are small and narrow, this can be hidden between the The symptomatology is fairly typical in all patients gastric folds and can be easily missed. Once the diagnosis except in one. Symptoms consist of vague peptic has been suspected by the barium enema, endoscopy symptoms, fecal vomiting and fecal eructation. Duration serves as a useful purpose of actually visualizing the fistula of symptoms ranged from one month to four years. In and obtaining cytological and biopsy materials to clarify some patients, abdominal mass was the initial sign. Loss the nature of this communication. of weight was noted in most of these patients and in one The therapy of this entity is primary excision and series, as high as 80%o ofthe patients had loss of weight and anastomosis.10 In the past, staged operations have been 30%o of them had fecal eructation.8 Anemia and malnutri- recommended with initial colostomy, but if the disease is tion were associated findings as noted in our group of not active, the primary excision may be accomplished patients. without any significant increase in morbidity and mortal-
240 ity. If active inflammatory
KUMAR AND OTHERS
with peritonitis is present, a more conservative approach such as, staged procedure with initial colostomy may be indicated. processes
References 1. Barter, K. W., Jr., Waush, J. and Priestly, J. T.: Operation in One-Stage for Gastrojejunocolic Fistula. Surg. Clin. North Am., 42:1443, 1963. 2. Broders, W. C.: Benign Gastrocolic Fistula. Report of Two Cases. Am. Surg., 39:342-3, 1973. 3. Dickson, W. J.: Gastrolic Fistula. Canad. Med. Assoc. J., 18:272, 1928. 4. Frieberger, R. H., Kammerev, W. H. and Rijelis, A. L.: Peptic Ulcers in Rheumatoid Patients Receiving Corticosteroid Therapy. Radiology, 71:542-547, 1958. 5. Hoffman, R. D.: Gastrocolic Fistula and Gastric Ulcer with Prolonged Glucocorticoid Therapy. JAMA, 195:6:493, 1966.
Ann. Surg.
August 1976
6. Lowden, 0. B. E.: Gastrojejunocolic Fistula. Br. J. Surg., 41:113, 1963. 7. Lynch, R. C. and Boese, J. L.: Carcinoic Tumor of Transverse Colon Complicated by Gastrocolic Fistula. Surgery, 38:3:600, 1955. 8. Marshall, S. F. and Kund, H. J.: Gastrojejunocolic and Gastrocolic Fistula. Ann. Surg., 145:770, 1957. 9. Pein, N. K.: Neonatal Gastrocolic Fistula. Lancet, 2:53, 1948. 10. Peter, M. and Benfield, J.: Benign Gastroenteric Fistula and Aspirin Abuse. Arch. Surg., 104:787, 1972. 11. Schweitzer, R. J. and Osborne, M. P.: Gastrocolic Fistula Complicating Carcinoma: Report of a Case due to Carcinoma of Colon with Successful Resection. Am. J. Surg., 85:775, 1953. 12. Smith, D. L. and Claggett, 0. T.: Gastrocolic Fistula Secondary to Benign Ulcer. Report of a Case. Surgery, 58:634, 1965. 13. Theony, R. H., Hodson, J. R. and Scudamore, H. H.: Roentgenologic Diagnosis of Gastrocolic and Gastrojejunocolic Fistulas. Am. J. Roentgen. Radium Ther. Nucl. Med., 38:876, 1960.
