GASTRO-COLIC GASTRO-COLIC FISTULAFISTULA

Presented byPresented by

DR. MD. YUNUS HAROON CHOWDHURYDR. MD. YUNUS HAROON CHOWDHURYStudent of MSStudent of MS

(General Surgery)(General Surgery)CMCCMC

Introduction:Introduction:

It is an abnormal communication between It is an abnormal communication between segment of stomach and transverse colon.segment of stomach and transverse colon.

It is a rare,late and severe disorder due to either It is a rare,late and severe disorder due to either benign or malignant conditions of GIT.benign or malignant conditions of GIT.

It may be spontaneous eg-benign PUD,IBD or It may be spontaneous eg-benign PUD,IBD or malignancy or may be iotrogenic eg-post surgery malignancy or may be iotrogenic eg-post surgery (gastrojejunostomy/Billroth ll (gastrojejunostomy/Billroth ll operation),endoscopic manipulation of GIT. operation),endoscopic manipulation of GIT.

History:History:

1st reported case was in 1755 by Haller1st reported case was in 1755 by Haller

In 1900 Zweig collected 70 cases from In 1900 Zweig collected 70 cases from literature of which 11 diagnosed in ante literature of which 11 diagnosed in ante mortem, others in post mortem.mortem, others in post mortem.

Classification & Etiology:Classification & Etiology:Benign ConditionBenign Condition::

1. Chronic PUD : drug induced eg-Aspirin, NSAID, Cortico steroid .1. Chronic PUD : drug induced eg-Aspirin, NSAID, Cortico steroid .

2. Previous Gastric Surgery : Gastro jejunostomy, Billroth II Surgery.2. Previous Gastric Surgery : Gastro jejunostomy, Billroth II Surgery.

3. Inflammatory bowel disease : Crohn's disease, perforated colonic 3. Inflammatory bowel disease : Crohn's disease, perforated colonic diverticulitis, diverticulitis, Ulcerative colitis.Ulcerative colitis.

4. Intra abdominal abscess: eg. Pancreatic abscess, Appendicular 4. Intra abdominal abscess: eg. Pancreatic abscess, Appendicular abscess.abscess.

5. Post Traumatic: eg. Traumatic Pancreatic Fistula, Instrumention eg : 5. Post Traumatic: eg. Traumatic Pancreatic Fistula, Instrumention eg : Endoscopy, Endoscopy, Colonoscopy, Colonoscopy,

6. Tuberculosis.6. Tuberculosis.

7. Syphilis.7. Syphilis.

8. Retro Peritoneal Sarcoma.8. Retro Peritoneal Sarcoma.

Malignant Conditions:Malignant Conditions:

1. Locally advanced caof stomach & colon.1. Locally advanced caof stomach & colon.

2. Gastric Lymphoma. 2. Gastric Lymphoma.

3. Carcinoid tumour of colon.3. Carcinoid tumour of colon.

4. Rarely Metastatic Tumour.4. Rarely Metastatic Tumour.

Discussion of Individual Common Discussion of Individual Common EitiologyEitiology

1.1. GCF following benign PUD : GCF following benign PUD :

a) common in the past decades before development of surgical a) common in the past decades before development of surgical procedure and advanced therapeutic treatment.procedure and advanced therapeutic treatment.

b) Now it is very rare, only 30 cases published in the literature.b) Now it is very rare, only 30 cases published in the literature.

c) Mostly due to NSAID, Cortico steroid intake.c) Mostly due to NSAID, Cortico steroid intake.

d) GU 6 times more common then DU.d) GU 6 times more common then DU.

e) Most are limited in antrum near greater curvature.e) Most are limited in antrum near greater curvature.

f) Usual ages 4th and 5th decade.f) Usual ages 4th and 5th decade.

2. 2. GCF Following Gastric Surgery :GCF Following Gastric Surgery :

a) Apparently rare now due to better theraputic a) Apparently rare now due to better theraputic approach. Marshall and Hansen reported one GCF approach. Marshall and Hansen reported one GCF out of 7 developed marginal ulcer. Subramanisivam out of 7 developed marginal ulcer. Subramanisivam reported 12 cases over 15 years of study. Turkish reported 12 cases over 15 years of study. Turkish author has experienced 10 cases out of 593 in 10 author has experienced 10 cases out of 593 in 10 years series.years series.

b) It may devoloped 20 years after surgery. b) It may devoloped 20 years after surgery.

c) It is a rare and late complication of stomal/marginal c) It is a rare and late complication of stomal/marginal ulcer.ulcer.

d) It develops as a result of inadequate resection of d) It develops as a result of inadequate resection of stomach and incomplete Vegotomy. stomach and incomplete Vegotomy.

e) Usually between greater curvature of the stomach and e) Usually between greater curvature of the stomach and distal half of the T colony due to close proximity distal half of the T colony due to close proximity separated by Gastro colic omentum.separated by Gastro colic omentum.

3.3. GCF due to stomach and T. colon carcinoma :GCF due to stomach and T. colon carcinoma :

a) In 1912 Voerhoeve collected 105 cases and found 3.75% due to CA a) In 1912 Voerhoeve collected 105 cases and found 3.75% due to CA stomach.stomach.

b) 1924 Verbrugge collected 216 cases of which 121 where due to b) 1924 Verbrugge collected 216 cases of which 121 where due to primary colonic or gastric carcinoma.primary colonic or gastric carcinoma.

c) Now, it becomes rare, could be due to early diagnosis and treatment c) Now, it becomes rare, could be due to early diagnosis and treatment of carcinoma.of carcinoma.

d) Carcinoma colon is most common cause in western countries and d) Carcinoma colon is most common cause in western countries and CA stomach in Japan. CA stomach in Japan.

e) In an average of 1,500 cases in CA stomach and 3,200 cases of CA e) In an average of 1,500 cases in CA stomach and 3,200 cases of CA colon only 11 was found developed GCF out of which 1 is due colon only 11 was found developed GCF out of which 1 is due

to to CA stomach.CA stomach.

f) Mostly common after 6th decade.f) Mostly common after 6th decade.

g) Carcinoma is middle and distal T. colon and GC of stomach was g) Carcinoma is middle and distal T. colon and GC of stomach was found involved in 13 cases out of 14.found involved in 13 cases out of 14.

h) Erosion of tumour to the adjacent organ and with an ulcerated h) Erosion of tumour to the adjacent organ and with an ulcerated tumour peritoneal reaction followed by exudation and necrosis of tumour peritoneal reaction followed by exudation and necrosis of adjacent organ produces perforation and fistula.adjacent organ produces perforation and fistula.

4. 4. GCF as a complication of PEGGCF as a complication of PEG ::

a) PEG commonly given for long term nutrition in some a) PEG commonly given for long term nutrition in some cases like CVD, Oropharyangial CA, oesophageal cases like CVD, Oropharyangial CA, oesophageal stricture, fistula and carcinoma. stricture, fistula and carcinoma.

b) It is rare and late complication which usually develops b) It is rare and late complication which usually develops 8 months later of PEG tube insertion.8 months later of PEG tube insertion.

c) In adult incidence was .5% and in children 1.3% c) In adult incidence was .5% and in children 1.3% (Larsen et al 1987).(Larsen et al 1987).

d) Possible cause include-Previous surgery with d) Possible cause include-Previous surgery with adhesion of T colon to ant. abdominal wall, rotation adhesion of T colon to ant. abdominal wall, rotation of of stomach during PEG tube insertion most common stomach during PEG tube insertion most common in in child due to more rudimentary gastro colic child due to more rudimentary gastro colic ligament, ligament, mucosal erosion and fistula formation due mucosal erosion and fistula formation due to to chronic irritation by PEG tube.chronic irritation by PEG tube.

Clinical Presentation:Clinical Presentation:

Depends on size of fistual and primary pathology. Depends on size of fistual and primary pathology.

Mershall and Hansen decribed the triad of symptoms Mershall and Hansen decribed the triad of symptoms associated with a GCF as-associated with a GCF as-

a) Diarrhea- Positive in 90% cases.More than 8-12 a) Diarrhea- Positive in 90% cases.More than 8-12 motion/per day.Usually watery and motion/per day.Usually watery and immediately after taking food. immediately after taking food.

b) Weight loss-5-15 KG over 2-3 months period.b) Weight loss-5-15 KG over 2-3 months period.

c) Eructation of fecal smelling gas.c) Eructation of fecal smelling gas.

d) Other features are :d) Other features are :

(1) Vomitting (Feculant).(1) Vomitting (Feculant).

(2) Nausia and anoraxia.(2) Nausia and anoraxia.

(3) Upper abd pain 64% in malignant (3) Upper abd pain 64% in malignant disease. disease.

(4) Undigested food & drugs in stool.(4) Undigested food & drugs in stool.

(5) Melaena.(5) Melaena.

(6) Moderate to severe malnutrition(6) Moderate to severe malnutrition..

e) Besides post operative patient will show scar e) Besides post operative patient will show scar mark.mark.

f) Marginal ulcer patient will show upper abd f) Marginal ulcer patient will show upper abd tenderness. tenderness.

g) Malignant patient will show lump in the upper g) Malignant patient will show lump in the upper abd.abd.

Investigation:Investigation:a. Ba-Enema 95% sensitive (Thoemy et al)a. Ba-Enema 95% sensitive (Thoemy et al)

b. upper GI enema (water soluble contrast) 27% sensitive.b. upper GI enema (water soluble contrast) 27% sensitive.

c. Contrast CT will show-exact pathology & anatomy of the fistula & surrounding c. Contrast CT will show-exact pathology & anatomy of the fistula & surrounding organs.organs.

d. Upper GI endoscopy & Colonoscopy-to visualize fistula tract & taking d. Upper GI endoscopy & Colonoscopy-to visualize fistula tract & taking histopathology, Operator depended, may be missed due to inadequate histopathology, Operator depended, may be missed due to inadequate preparation preparation and presence of thick gastric mucosal fold. and presence of thick gastric mucosal fold.

e. USG of the upper abd-Important for fistula of genito urinary tract, colour doppler e. USG of the upper abd-Important for fistula of genito urinary tract, colour doppler USG with manual or transducer compression may show fluid motion among USG with manual or transducer compression may show fluid motion among hollow viscus, irregual hypo echoic shadow with central enechoic hollow viscus, irregual hypo echoic shadow with central enechoic

component component due to entrapped gas.due to entrapped gas.

g. Haematological-Hb-concentration (low according to severity of illness), low total g. Haematological-Hb-concentration (low according to severity of illness), low total serum protein and albumin, electrolyte imbalance, low serum lipid profile, serum protein and albumin, electrolyte imbalance, low serum lipid profile,

CEA CEA in malignant cases, blood culture to exclude systemic sepsis, in malignant cases, blood culture to exclude systemic sepsis,

h. Stool : Macroscopy and Microscopy with OBT and stool culture. h. Stool : Macroscopy and Microscopy with OBT and stool culture.

i. Anthropometric and laboratory assessment of nutritional status. i. Anthropometric and laboratory assessment of nutritional status.

Fig-1Fig-1

Fig-2Fig-2

Colonoscopic findings reveal two fistulae (Colonoscopic findings reveal two fistulae (FF) at the distal transverse colon.) at the distal transverse colon.

Both the urograffin enema and barium meal confirmed the diagnosis of Both the urograffin enema and barium meal confirmed the diagnosis of

gastrojejunocolic fistula gastrojejunocolic fistula

Fig-4Fig-4

Treatment :Treatment :

1. Aggressive correction of Fluid & electrolyte imbalance, 1. Aggressive correction of Fluid & electrolyte imbalance, Correction of anemia by B.T., Control of sepsis by specific Correction of anemia by B.T., Control of sepsis by specific antibiotic, Improvement of nutritional status by TPN & antibiotic, Improvement of nutritional status by TPN & bowel rest for at least 3 weeks before definitive surgery, In bowel rest for at least 3 weeks before definitive surgery, In very poor Venus access diagnostic laparoscopy & feeding very poor Venus access diagnostic laparoscopy & feeding jejunostomy placement.jejunostomy placement.

2.Spontaneous closure expected in case of GCF by PEG 2.Spontaneous closure expected in case of GCF by PEG tube. tube.

3. Medical treatment with spontaneous closure- patient 3. Medical treatment with spontaneous closure- patient having mild symptom, very small fistula opening, In having mild symptom, very small fistula opening, In patient patient with benign PUD with drug induced GCF, with benign PUD with drug induced GCF, withdrawal of withdrawal of drugs & ulcer healing drugs e.g H2 drugs & ulcer healing drugs e.g H2 blocker(300 mg TDS), blocker(300 mg TDS), proton pump inhibitor (40 mg BD) + proton pump inhibitor (40 mg BD) + Sucralfate 1 gm QID- for 3 Sucralfate 1 gm QID- for 3 months. Time of healing 2 to 16 months. Time of healing 2 to 16 weeks average 9 weeks. weeks average 9 weeks. Infliximab (MCab) & other disease Infliximab (MCab) & other disease modifier in IBD. modifier in IBD.

Macroscopic view of the resected specimen.Macroscopic view of the resected specimen. The fistula measures 1 cm in diameter. The fistula measures 1 cm in diameter. SS, stomach; , stomach; AA, antrum; , antrum; JJ, jejunum;, jejunum;TT, transverse colon., transverse colon.

4.4.Surgical Treatment ;Surgical Treatment ;

a)Best procedure for treatment failure benign PUD a)Best procedure for treatment failure benign PUD with with GCF, GCF, post gastro jejunostomy & post Bilroth II post gastro jejunostomy & post Bilroth II with with stomal ulceration & GCF patient, resectable stomal ulceration & GCF patient, resectable colonic colonic or gastric Ca. or gastric Ca.

b)Enblock resection of fistula and revision b)Enblock resection of fistula and revision gastrectomy, partial resection of jejunum and colon gastrectomy, partial resection of jejunum and colon that is involved in the fistula, restoration of GI that is involved in the fistula, restoration of GI continuty continuty by G-j-ostomy (Roux-en-Y) J-J-ostomy C-by G-j-ostomy (Roux-en-Y) J-J-ostomy C- C-C-ostomy, Vagotomy (if not done previously)ostomy, Vagotomy (if not done previously)

c)Staged procedure by initial colostomy may be c)Staged procedure by initial colostomy may be indicated in case of Severe inflammation & indicated in case of Severe inflammation & peritonitis.peritonitis.

d)If resectable carcinoma- Hemil colectomy, Partial d)If resectable carcinoma- Hemil colectomy, Partial (distal 2/3 rd ) gastrectomy, Enblock fistulectomy, R-en-Y (distal 2/3 rd ) gastrectomy, Enblock fistulectomy, R-en-Y gastro jejunostomy, ileo-colic or colo-colic anastomosis. gastro jejunostomy, ileo-colic or colo-colic anastomosis.

ConclusionConclusion Gastro colic fistula remains a late, rare and dreadful complication Gastro colic fistula remains a late, rare and dreadful complication of cancer, inflammatory bowel disease, benign PUD and after of cancer, inflammatory bowel disease, benign PUD and after general surgical procedure. general surgical procedure. An understanding of the path physiology & risk factors for An understanding of the path physiology & risk factors for development may minimize their creation as well as provide a development may minimize their creation as well as provide a sound plan for management.sound plan for management.Early recognition & resuscitation with control of sepsis & Early recognition & resuscitation with control of sepsis & provision of nutritional support may limit associate complication.provision of nutritional support may limit associate complication.Anatomical & etiological characteristic of each fistula may provide Anatomical & etiological characteristic of each fistula may provide information about likelihood of spontaneous closure or suggest information about likelihood of spontaneous closure or suggest earlier operative management.earlier operative management.Careful planning and technique of surgery with involvement of Careful planning and technique of surgery with involvement of multi disciplinary team will give best outcome. multi disciplinary team will give best outcome. Finally post operative maintenance of adequate nutritional, Finally post operative maintenance of adequate nutritional, physical & emotional support may allow restoration of patient to a physical & emotional support may allow restoration of patient to a functional & productive role in society. functional & productive role in society.