Gastrojejunocolic fistula after gastrojejenostomy

A 51-year-old male present with chronic diarrhoea immediately after meals, vomiting and unintentional weight loss of around 20 Kg over 2 years. Past medical history revealed gastrojejunostomy for duodenal ulcer perforation in 2000. On physical examination, the patient was cachectic with pedal oedema and abdominal distention. Laboratory parameters revealed malnutrition with albumin level of 1.7 g/dL (range, 3.5 to 5.0), protein level of 3.4 g/dL (range, 6.4 to 8.3), Haemoglobin of 9.9 g/dL (range, 13.5-17.5) and Potassium of 2.7mEq/L (range, 3.5 to 5.1). Contrast-enhanced CT abdomen was subsequently performed.

Contrast-enhanced CT Abdomen was performed. Side-to-side gastrojejunal anastomosis noted in keeping with prior surgical history (Figure 1).  Presence of positive oral contrast within the descending colon with absence of the contrast in the ascending colon was noted (Figure 2). A fistulous communication noted between the jejunum and posterior wall of the transverse colon just distal to the GJ site (Figure 3). Passage of oral contrast through the fistula was demonstrated (Figure 4,5). Diffuse circumferential colonic submucosal oedema is noted, which was due to hypoproteinaemia. There was no mass lesion. No signs of bowel obstruction/ perforation were present.

Background: Proton pump inhibitors, H2 receptor blockers, and the elimination of Helicobacter pylori have all helped to significantly reduce the requirement for surgical treatment of peptic ulcer disease.[1] One of the rare and late complication of the surgical procedure of gastrectomy and gastrojejunostomy used to treat recurrent peptic ulcer disease is known as gastrojejunocolic fistula (GJF).[2]

Clinical Perspective: Diarrhea, epigastric discomfort, gastrointestinal haemorrhage, faecal vomiting, weight loss, and weakness are all signs of GJF. Common laboratory results include anaemia, leucocytosis, electrolyte abnormalities, and hypoalbuminemia.[3]

Imaging Perspective: The imaging modality of choice is CT scan, contrast-enhanced if there are no contraindications. Computed tomography is used to determine complex fistulae and to exclude extra-abdominal diseases that may define underlying aetiology.[4] It is important that the study be performed following the administration of oral and/or rectal contrast agents to allow fluid-filled loops of bowel to be distinguished from extraluminal fluid collection.[5,6]

Presence of contrast in abnormal locations, as seen in this case, where contrast was noted in the descending colon without being present in the ascending colon, should raise suspicion for a fistulous communication.

Outcome: Our patient underwent laparotomy in which Gastrojejunal anastomosis was noted. Transverse colon was noted on the left side communicating with the jejunum forming jejunocolic fistula. Resection of fistulous bowel with Jejunojejunal end to end anastomosis was performed, Transverse colon was brought out as stoma and distal part as mucous fistula. Histopathological examination of the fistulous bowel showed nonspecific inflammatory changes.

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Teaching points: CT with oral contrast, preferably positive, is the commonest technique to confirm the presence of a gastrocolic fistula.

Malignancies remain the most common cause of an enteric fistula and CECT is the gold standard to exclude such underlying aetiology.

Presence of contrast in abnormal locations provides a diagnostic clue in determining the presence of a fistula.