A man with a leaky drain

Abstract

In August, 1998, a 57-year-old former staff nurse was admitted for assessment of severe weight loss and diarrhoea, passing as many as 20 watery pale stools per day. These symptoms had been present for 3 years. Over this time his weight had fallen from 88 to 52 kg. Within the previous year his serum albumin had fallen from 35 to 14 g/L, and his alkaline phosphatase and alanine transaminase had risen to 1411 IU/L and 150 IU/L, respectively. His past medical history was unremarkable apart from a gastrojejunostomy and vagotomy for peptic ulcer disease in 1973. Since his initial presentation with diarrhoea he had had various investigations. Three upper gastrointestinal endoscopies had shown an apparently healthy stoma and no other abnormalities. Biopsy specimens of the jejunum had been normal. Two colonoscopies had shown no abnormalities, but colonic specimens showed a slight increase in chronic inflammatory cells. Two barium meals with followthrough studies had shown non-specific mucosal thickening in the small bowel and possible narrowing of the terminal ileum. C-reactive protein, ferritin, and red cell folate concentrations were normal, although serum vitamin B12 concentration had been low at original presentation and supplemented parenterally. Crohn’s disease had been provisionally diagnosed, but treatment with mesalazine and steroids had made no impact on his symptoms. A liver biopsy sample was obtained, and this showed florid steatosis. An endoscopic retrograde cholangiogram was normal. A glucose hydrogen breath test showed a large rise from 4 to 139 parts per million (normal <12), consistent with heavy small bowel bacterial overgrowth or a fistula. A barium enema was done, which showed a gastrojejunocolic fistula at the level of the transverse colon (figure). The patient then volunteered a history of faeculent eructation which was so severe that during a holiday flight the cabin crew had been requested to spray air freshener by fellow passengers. Parenteral nutrition was started and his weight and albumin began to rise. At laparotomy the fistula was identified and resected. A new gastroenterostomy was not made. Pathological examination of the resected specimen showed a 23 mm irregular fistulous opening with no evidence of malignant disease in the surrounding mucosa. The patient made an excellent recovery and when last seen in April, 1999, was 77 kg with a normal albumin. He is now able to travel on public transport without fear of embarrassment. Barium enema examination There is contrast in the colon (A) which then entered stomach (B) and jenunum (C) through the gastrojejunocolic fistula.