Tropical Gastroenterology 2013;34(4):273–274
8. O’Sullivan MJ, McGreal G, Walsh JG, Redmond HP. Trichobezoar. J R Soc Med. 2001;94:68–70.
hemoglobin to 11.4 g/dl. Ultrasonography of abdomen and pelvis was normal. An upper gastrointestinal endoscopy showed gastrojejunostomy with an excavating stomal ulcer about 10mm in diameter. There was no evidence of malignancy. Barium enema showed the distal colon to be filled up with
Barium emesis during barium enema study: a definitive sign of gastrojejunocolic fistula Introduction Gastrojejunocolic fistula (GJCF) is a rare and late complication of gastrectomy and gastrojejunostomyperformed for peptic ulcer disease.Generally GJCF is considered to be induced by a stomal ulcer due to inadequate gastricresection, incompleteness of vagotomy and long afferent loop.1,2The most frequent symptoms of GJCF are upper abdominal pain, severe weight loss, diarrhea,gastrointestinal bleeding and sometimes fecal vomiting. 3 Most patients with GJCF present with asymptom triad of fecal vomiting/breath, chronic diarrhea, and weight loss.4-6 The diagnostic investigation of choice to date has been barium enema, which has a sensitivity of 95% for this condition.6,7 However with improvement of endoscopic imaging and instruments, gastroscopy and colonoscopy may now have
Figure 1:
Barium enema showing barium directly entering the stomach from splenic flexure
Figure 2:
Barium lining the esophageal wall after vomiting out barium
a role in the diagnosis of GJCF. We present here a case of a 65year-old man with gastrojejunocolic fistula in whom interestingly the diagnosis was confirmed by barium emesis during barium enema.
Case report A 65-year-old male presented with diarrhea for 1 year which was aggravated during the past 2 months. Stool frequency was 10-12 times/day, and stool contained undigested food particles and mucous without blood. There was weight loss of about 10 kg during the last 2 months. He also complained of feculent vomiting during this period. His medical history included a surgery (Billorth’s II) for peptic ulcer disease 30 years ago. He appeared pale, cachectic and dehydrated. Abdominal examination revealed only a midline scar over the abdomen. The laboratory investigationson admission showed iron deficiency anemia withhemoglobin of 8.4 g/dland hypoalbuminaemia with serum albumin 2g/dl. He was transfused with two units of blood,which improved the
Tropical Gastroenterology 2013;34(4):274–277
barium up to splenic flexure; however no barium was seen in the transverse colon and most of the barium entered the
preoperatively. SHIVARAM PRASAD SINGH1 MANAS KUMAR PANIGRAHI1 DEBASIS MISRA1 BIJAY MISRA1 SANJIB KUMAR KAR1 CHITTA RANJAN PANDA1 HARIBHAKTI SEBA DAS1 OMPRAKASH AGRAWAL2 CHUDAMANI MEHER2
stomach (Figure 1) and esophagus. The patient vomited out considerable amount of barium (Figure 2). Subsequently, barium was also seen in the jejunum. Diagnosis of gastrojejunocolic fistula was established and elective surgery was planned. During surgery, a fistula was detected between the greater curvature of stomachand transverse colon.He underwent revision gastrectomy, segmental resection of the jejunum and transverse colon with end to end transverse colon anastomosis and Roux-en-Y gastrojejunostomy. The histological findings revealed that the fistula, which measured 5 cm, occurred adjacent to the stomalulcer. Recovery was uneventful and the patient remained well during a followup of
Correspondence: Dr. Manas Kumar Panigrahi Department of Gastroenterology, SCB Medical College,1 Beam Diagnostic Centre, Bajrakabati Road, Ranihat,2 Cuttack, Odisha, India Email:
[email protected]
6 months.
References Discussion Gastrojejunocolic fistula formation is rare and its etiology is multifactorial. A GJCF can arise spontaneously or after previous gastric surgery, typically as a result of marginal ulceration after gastrojejunostomy for peptic ulcer disease.8Since fistula formation needs a20–30-year latent period after the initial surgery, this severe and rare complication may still be seen in present day practice. Therefore, GJCF is still an important complication which may be encountered in regions where peptic ulcer is common and the patients were subjected to surgery 2 to 3 decades ago.9 In GJCF an upper gastrointestinal barium study or water soluble barium contrast enema may be performed to confirm the diagnosis. However since the flow in the fistula is predominantly from the transverse colon to stomach, barium meal may miss the diagnosis in30-70% of cases. Bariumenema has been found by Thoeny et al7 to have 95% diagnostic sensitivity as compared to the 27% sensitivity of upper GI tract barium studies. GJCF is best detected bybarium enema,
1. D’Amata G, Rahili A, Karimdjee-Soilihi B, Gelsi E, Avallone S, Benchimol D. Gastrojejunocolic fistula after gastric surgery for duodenal ulcer: case report. G Chir. 2006;27:360–2. 2. Subramaniasivam N, Ananthakrishnan N, Kate V, Smile SR, Jagdish S, Srinivasan K. Gastrojejunocolic fistula following surgery for peptic ulcer. Trop Gastroenterol. 1997;18:183–7. 3. Chung DP, Li RS, Leong HT. Diagnosis and current management of gastrojejunocolic fistula. Hong Kong Med J. 2001;7:439–41. 4. Alhan E, Calik A. Gastrojejunocolic fistula. Coloproctology. 1990;12:187–9. 5. Mathewson C. Preliminary Colostomy in the Management of Gastrocolic and Gastrojejunocolic Fistulae. Ann Surg. 1941;114:1004–10. 6. Lowdon AG. Gastrojejunocolic fistula. Br J Surg. 1953;41:113–28. 7. Thoeny RH, Hodgson JR, Scudamore HH. The roentgenologic diagnosis of gastrocolic and gastrojejunocolic fistulas. Am J Roentgenol Radium TherNucl Med. 1960;83:876–81. 8. Clark FD. Gastrocolic fistula secondary to right gastroepiploiccoronary artery bypass. Can J Surg. 2005;48:417–8. 9. Sorensen BM. Non malignant gastrointestinal shortcircuit. (Gastrojejunocolic fistula and gastroileostomy). Acta Chir Scand Suppl. 1969;396:67–70.
which confirms the diagnosis in 90-100% of cases. The nature of the fistula tract varies, and a computed tomography scan may reveal the underlying pathology such as an abscess, cancer or ulcer as well as the anatomy adjacent to the fistula. Upper and lower gastrointestinal endoscopy are excellent tools for visualizing the fistulous opening (especially in the stomach) and also allow preoperative histological confirmation.Negative findings on endoscopy do not rule out the diagnosis of a GJCF. One-stage en-bloc resection is feasible ifthe patient’s general condition is good or can be improved
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