S3131 An Unusual Case of Postprandial Diarrhea: Gastrocolic Fistula from Gastric Band Erosion

Abstract

Introduction: Bariatric surgery is increasingly performed nowadays. Gastroenterologists may encounter patients with its complications. Known complication of laparoscopic adjustable gastric banding (LAGB) include reflux, band slippage, erosion, pouch enlargement, and port breakage. We report a case with an unusual complication of LAGB. Case Description/Methods: A 45-year-old male with LAGB and atrial fibrillation presented with chronic diarrhea. Symptoms onset was 3 years ago after his partial small bowel resection when he presented with peritonitis. The patient reported loose stool within 15 minutes after each meal, abdominal pain, and 13-lbs weight loss. Physical exam was unremarkable. Laboratory data were within normal limits except mild anemia (Hgb of 12.9 g/dL) and mild renal impairment (Cr of 1.55 mg/dL). Upper GI study with small bowel follow through showed two separate channels arising from the proximal stomach with one connecting to the mid-transverse colon, suggesting a gastrocolic fistula (GCF) (figure 1A). CT scan of chest/abdomen/pelvis that was performed prior to barium studies was reviewed and demonstrated gastric erosion of the LAGB, with tethering of gastric cardia to the transverse colon with prolapse of the tubing into the distal transverse colon (figure 1B). Subsequent upper endoscopy showed an eroded gastric band in the gastric cardia and appeared to be extending through the gastric wall (figure 1C). Colonoscopy noted gastric band was entering transverse colon and extended distally (figure 1D). Surgical specimen of previous small bowel resection was reviewed and didn't show small bowel ischemia nor small bowel Crohn’s disease. The patient is currently evaluated by a bariatric surgeon for the definite treatment. Discussion: GCF is an uncommon manifestation of certain malignancies, pancreatitis, Crohn’s disease, peptic ulcer disease, and few cases related to other bariatric surgeries, usually with sleeve gastrectomy. LAGB related erosions of stomach, colon, and small bowel have been reported. To best of our knowledge, there are only 3 other cases of GCF related to LAGB. We report a rare complication of LAGB. Mechanism of GCF from LAGB is not fully understood, and is likely related to erosion of gastric wall from band pressure or foreign body reaction. Symptoms includes abdominal pain, weight loss, diarrhea, and sepsis. Diagnosis is made with upper GI series, contrast enhanced CT and endoscopic visualization. Surgery is the mainstay of treatment with removal of band and closure of fistula.Figure 1.: Endoscopic image of gastric ulcer in first case (A). Microscopic image H&E stained 400x of lymphoepithelial lesion with surrounding lymphocyte mucosal invasion (B). Endoscopic image of polypoid lesion in second case (C). Microscopic image H&E stained 200x of diffuse lymphocyte invasion into the lamina propria and muscularis mucosa (D).