By PATRICK FITZGEm~I,D, M.D., M.Ch., M.~c.. Associate Professor of Surge~T, U.C.I). :
Surgeon to St. Vincent's Hospital. Dubli',.
a l ia
JOSEPH P. McMuLLIN, M.Ch., F.R.C.S., U~tiversily Surgical Tutor, St. Vince~t's IIospita!, D,blb~.
G ASTRO-JEJUNOCOLIC fistula is a condition in which there is an "abnormal communication between the colon and the stomach. These fistulae can be divided into two distinct groups :
(1) those arising without t)revious surgical interference; (2) those following surgical intervention.
Group (1) consists of (a) fistulae arising fr()m carcinomata ot' the stomach or colon, (b) arising from infective processes such as tuber- culosis, syphilis or diverticulitis, and (c) traumatic fistulae due to per- forating wounds. This entire group comprises not more than 5-1(} per cent. of the total of gastro-jejunocolic fistulae. It is of a different aetiology and will not be discussed further in the paper.
Group (2) consists of fistulae arising from gastro-jejunal ulceration, following on some type of operation for gastro-duodenal ulceration. ~astro-jejunocolic fistula is, therefore, as Lowdon :~ points out, 90 per cent.
a man-made disease. It is pertinent therefore to recall that the first gastro-enterostomy was performed by WSlfler at the suggestion of his assistant, Nicoladini in 1881 ; the fitut gastro-jejunal ulcer was reported by Braun in 1899, while the first gastro-jejunocolic fistula was reported by Czerny in 1903. Since that time 320 cases have been reported on by Bornstein ~ in 1941, 1o which Lowdon added 40 more, collected from the literature in 1953.
Incide~,ce. Of all the operati(ms for duodenal ulcer which may be followed by this serious complication, posterior gastro-enterostomy has the doubtful distinction of being the most likely precursor. Gastro- jejunal ulceration occurs in 15-20 per cent. of gastro-enterostomies per- formed for duodenal ulcer in men, and fistulae develop in 15 per cent,. ()f stomal ulcers consequent to posterior gastro-enterostomy.
Other operations for duodenal ulcer which may be indicted in this respect a~c :
(1) Anteeolic gastro-enterostomy. (2) Devine's exclusion operation. (3) Braun's entcro-anastomosis. (4) Roux en Y gastro-enterostomy. (5) Rarely after gastrectomy unless the amount reseeted has been
inadequate. Fistulae are seldom encountered after any type of operation for
gastric ulcer and almost never occur after resections for carcinoma of the stomach. '~
*Communicated to the Section of Surgely, 7th Feb., I.(!58.
GASTRO-JEJUNOCOLIC F ISTULA 23I
Subsequent to Czerny's case, reports of cases of gastro-jejunal ulcera- tion and of gastro-jejunocolic fistulae gradually increased in frequency and seem to have reached their peak in the 1920s and 1930s. Possibly the condition is now less frequent, owing to the fact that posterior gastro-enterostomy has not been in favour for the past decade, while gastrectomy of some sort is now the standard surgical method of treat- ment of duodenal ulceration. Thus we can look forward to this com- plication becoming rarer still, because the incidence of stomal ulceration following gastrectomy is about 2 per cent. of what it is for gastro- enterostomy. Therefore we should see only one-tenth of the number of fistulae in the next two decades that we saw in the past two.
Age and Sex. The most striking feature of the condition is that it pccurs almost exclusively in males. To date, out of a total number of about 400 reported, there have been only five cases of gastro-jejunocolic fistulae in women. This note adds one more.
The commonest age for the occurrence of gastro-jejunocolic fistulae is the ulcer age group, i.e., between 30 and 50 years, but cases have been reported as early as two years of age and as late as the eighth decade.
The pathogenesis of gastro-jejunocolic fistula is by its nature closely bound to that of stomal ulcer. The occurrence of the latter is characteris- tically associated with a strong duodenal ulcer diathesis, peculiar to the male, characterised by an intractable ulcer and with a tendency to per- sistence or recurrence of hyperchlorhydria, even after a gastrectomy of average dimensions.
The nature of the operation, particularly when the colon has been brought into close and fixed relationship with the stomach, as in posterior gastro-enterostomy, predisposes to the establishment of a fistula. Admittedly, posterior gastro-enterostomy was the commonest type of operation performed for duodenal ulcer, and therefore the predominance of its complication by fistula formation becomes statistically loaded. How- ever, the anatomical arrangement of a posterior gastro-enterostomy un- doubtedly favours the development of a colic fistula once stomal ulcera- tion is established. The liability of these ulcers to perforate, the posterior relation of the stoma to the colon and its relative fixity create an ideal status quo for the establishment of a fistula between colon and jejunum.
The length of time taken for a fistula to establish itself after the initial operation, varies from 2 months to 35 years.' The average of all known cases is 4.5 years.
Pathology. The fistulous track usually runs between colon and jejunum, less
commonly between the colon and the stoma, and rather infrequently between the colon and the stomach. 1 The efferent loop of the jejunum, an inch or so below the gastro-enterostomy, is the usual site of the fistula (Fig. I (a)). The track may be wide and sho~t, or long and narrow-- wide enough to admit two fingers and narrow enough to admit only a fine probe. It is lined by glandular epithelium and the junction between colonic and jejunal epithelium is usually abrupt and well marked. Generally, there is marked lymphocytic infiltration of the adjacent gastric and jejunal mucosa2
232 IR ISH JOURNAL OF MDDICAL SCIENCE
F,(~. la. Usual site for gastrojejunocolic fistula.
Fro. lb. Erroneous 'shunt' explanation of diarrhoea in gastrojejunocolic fistula.
FIo. lc. Pfeiffer's explanation of the diarrhoea; that i~ is caused by the develop-
ment of f~ecal gastrojejunitis from the colonic reflux. FxG. ld.
Relief of the diarrhoea by establishment of a proximal colostomy demonstrates the validity of Pfeiffer's explanation.
Inflammatory reaction in the serosa and the involved organs may be marked, and usually is, but in our first case and in some of those re- ported by Rhind ~ the fistula was small and unexpected and/he inflam- mation and adhesion formation was slight.
Active stomal ulceration may rarely, and active duodenal ulceration may occasionally, be present once the gastro-jejunocolie fistula is formed ; if so, the h~ards of the operative procedure to cure the fistula are natural ly increased. (See Case No. 3.) However, they are rarely present, as faecal contamination of the stomach produces a gastritis which lowers the production of acid juice and leads to healing of the stomal ulcer and of the duodenal ulcer if they be still active.
Signs and Symptoms. The classical signs and symptoms of a gastro-jejunocolic fistula form a
tr iad : (1) Profuse or continuous diarrhoea. (2) Loss of weight. (3) Faecal vomiting.
The cause of the diarrhoea has been the subject of much controversy. Up to 1941, it was thought 1 8 4 that the diarrhoea was due to a colitis
GASTRO-JEJUNOCOLIC FISTULA 233
caused by the entry of acid stomach contents into the colon via the fistula. (Fig. I (b).) But Pfeiffer ~ showed conclusively that it is due: to the presence of faecal matter in the jejunum causing a jejunitis and reflux gastritis, rather than of stomach contents in the colon. (Fig. I (c).) Colostomy proximal to the fistula which diverts the faecal stream, relieves the diarrhoea very quickly, because the jejunitis apparently subsides in a few days, once the defunctioncd colonic segment has become inactive. The portion of colon distal to the colostomy is still connected to the stomach by the fistulous track and gastric contents could still enter the distal or defunctioned part of the colon by this mute. (Fig. I (d).) Thus the alleviation of the frequent loose motions by the proximal colos- tomy indicates that the diarrhoea is not due to irritation of the colon by an abnormal shunt of gastric contents into the colon.
Other signs and symptoms which occur rather less frequently are : (4) Faecal smell of the breath with foul belching due to the presence
of faeces or flatus in the stomach. (5) Peri-umbilical pain, or pain in the hypochondrium which may
be colicky in nature. However, the establishment of the fistula may produce a sudden relief of the stomal ulcer pain, because the gastritis consequent on the establishment of the fistula may cause an aehlorhydria which allows the stomal ulcer to heal.
(6) Borborygmi due to small intestinal "hurry " which accompanies the jejunitis.
(7) Abdominal distension (for the same reason). (8) Oedema due to a lowered plasma protein, if malnutrition develops
as a result of the diarrhoea, gastritis and jejunitis. This series of signs and symptoms is usually present to some degree in 90-95 per cent. of cases. But there has been reported a small number of cases in which there were no symptoms of gastro- jejunocolic fistula and yet a fistula, usually of small size, was found at operation for stomal ulcer.' This was so in our fiI~t case. I f the possibility of the presence of a small gastro-jejuno- colic fistula were thought of in every case of stomal ulceration, pre-operative treatment of the small intestine could be carried out which would render a one-stage resection safer for the patient and easier for the surgeon.