Diarrhea With Severe Weight Loss Secondary to Gastrocolic Fistula (GCF)

Abstract

Introduction: Gastric resection for peptic ulcer disease has decreased over the past 2 decades and hence complications of surgery for peptic ulcer disease are seen less frequently in clinical practice. We report a case of a large GCF in a patient with a history of gastrectomy. Case Report: 54 year-old-female with a 30 pack year history of smoking, Billroth 11 gastrectomy for peptic ulcer disease and revision with a Roux-en-Y gastrojejunostomy for delayed gastric emptying presented with a 3-month history of severe weight loss and diarrhea. Her weight dropped from 130 lbs to 73 lbs. with passages of 10 to 20 watery pale stools a day, occurring 15 to 30 minutes after meals. She reported no melena or hematochezia nor vomiting. On examination, the patient was disheveled and emaciated (BMI 11.5). Vital signs were within normal limits. Mild periorbital edema was present. There was only mild abdominal tenderness and no organomegaly or ascites. There was 2+ pitting bilateral peripheral edema. Significant laboratory results: Complete blood count was normal. Basic metabolic profile was normal except for BUN 2 mg/dl, creatinine 0.2 mg/dl, albumin 1.5 g/dl, prealbumin 10 mg/dl, phosphorus 1.1 mg/dl. Stool specimen was negative. Gastroscopy revealed a large cleaned based gastric ulcer on the jejunal side of the gastrojelunal anastomosis with a severely stenotic jejunal orifice (1-2 mm opening); a large gastrocolic fistula (15 mm) which the scope easily traversed. Colonoscopy and ileoscopy were unremarkable except for the fistula which was identified in the transverse colon.The patient was placed on TPN and after 4 weeks underwent surgery with en bloc resection and primary anastomosis. Discussion: Gastrointestinal malignancies were reported previously as the most common causes of GCF. Recently, benign etiologies appear to be more common. These include complications of peptic ulcer disease and enteral feeding tubes. The most common presenting symptoms are diarrhea, weight loss and abdominal pain. Diagnosis is made by barium enema. Endoscopy are useful but may miss small fistulae. Treatment in most cases is surgical.Figure 1: Gastroscopy revealing a large cleaned base gastric ulcer with a 2-mm stenotic jejunal orifice and a 15-mm gastrocolic fistula.