230

GASTRO-dEdUNOCOLIG FISTULA*

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 i a

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 a n "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 fur ther 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 I S T U L A 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 s tandard 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 na ture closely bound to that of stomal ulcer. The occurrence of the la t ter 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 af ter a gastrectomy of average dimensions.

The na ture of the operation, par t icular ly 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 af ter 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 ra ther infrequent ly 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 na r row- - wide enough to admit two fingers and narrow enough to admit only a fine probe. I t is lined by glandular epithelium and the junct ion 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 I R I S H JOURNAL OF MDDICAL S C I E N C E

F,(~. la. Usual site for gastrojejunocolic fistula.

Fro. lb. Erroneous ' shun t ' 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.

Inf lammatory 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 a n d / h e 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 ~ a r d s of the operative procedure to cure the fistula are natura l ly increased. (See Case No. 3.) However, they are rare ly 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

t r iad : (1) Profuse or continuous diarrhoea. (2) Loss of weight. (3) Faecal vomiting.

T h e 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 " h u r r y " 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.

Diagnosis. Diagnosis is based on the history of previous operation and on the

signs and symptoms which have been discussed. Of the special tests, barium enema is the mos~ reliable method of demonstrating the abnormal connection between colon and jejunum, but occasionally barium meal will demonstrate the track when the enema will not. (Case No. 3.)

Treatment. Pre-operative treatment is directed : (1) to restore the fluid and electro-

lyte balance; (2) to return the blood picture to normal; (3) to sterilise the bowel and empty it as far as possible by enemata and gastric lavage.

The principles of the operation itself are : to remove the abnormal con- nection between jejunum and colon and to reduce the acid-bearing area of the stomach and the danger of recurrence of ulceration at the original

234 IRISH JOURNAL OF MEDICAL SCIENCE

duodenal or possibly stomal site. If the condition of the patient is poor, then one should do no more than a preliminary eolostomy at the hepatic fixture. This will reduce the diarrhoea and render the resection in six weeks' time a much safer procedure. It is inadvisable in such cases to delay the second operation beyond this time, as the duodenal ulcer originally present is more liable to become reactivated once the gastritis subsides. I f the condition of the patient is good, then a one-stage re- section should be undertaken.

The affected segments of the colon and jejunum are removed together with four-fifths of the stomach; continuity of the bowel is re-established and a fresh loop of jejunum is anastomosed with the remaining one-fifth of the stomach almost invariably in the ante-colic position.

Following are the reports of three cases of gastro-jejunoeolic fistulae treated by us in the past two years, presented in ascending order of pathological defects, with the associated appropriate modes of treatment.

Case 1. Mrs . M . M . Ae t 42 years.

She was a d m i t t e d to SS. J o h n a n d E l i zabe th Hosp i t a l , L o n d o n , on t h e 28th A u g u s t 1955, c o m p l a i n i n g o f pain in t he e p i g a s t r i u m a n d loss of weight . I n J a n u a r y , 1947, a g a s t r o - e n t e r o s t o m y h a d been e s t ab l i shed for duodena l ulcer, fol lowed in ) l a rch , 1947, by an. ar~astomosis b e t w e e n af ferent a n d efferent loops of t h e gas t ro -en t e ros tomy .

She was r e - a d m i t t e d in A u g u s t , 1955, wi th recur rence o f s y m p t o m s . The pah~ was periodic in re la t ion to food, a n d loss o f we igh t a m o u n t e d to n e a r l y 12 lb. in six m o n t h s . T h e r e was ne i the r d i a r rhoea nor vomith~g. Barium_ rr/eal showed m a r k e d s t o m a l u lcera t ion. B a r i u m e n e m a showed no abnorma l i ty . The ques t i on of gas t ro-

je junocol ic f i s tu la was no t cons idered fur ther . L a p a r o t o m y was p e r f o r m e d a f te r two weeks ' t r e a t m e n t by con t inuous mi l k drip. A t the opera t ion a pos te r io r gas t ro- e n b e r o s t o m y was found , a n d the re w a s a definite s toma l u lcer pa lpable in the efferent loop. T h e pos te r io r wall o f t he colon was a d h e r e n t to th i s a n d it was o n l y on sepa ra - t ion 9f t/he colon from. th i s si te t h a t a sma l l f is tula was found b e t w e e n it a n d the j e j u n u m .

T h e g a s t r o - e n t e r o s t o m y was d i s m a n t l e d and a formal four- f i f ths an ter ior Poly- I-Iofmeister g a s t r e c t o m y per fo rmed . T he open ing in the colon was smal l , a d m i t t i n g t h e t ip o f t he l i t t le finger. The i n d u r a t e d edge was excised ~md the hole closed w i thou t na r rowing t h e gut . R e c o v e r y was uneven t fu l . She was d i scha rged in th ree weeks. W h e n l a s t hea rd o f in December , 1957, she h a d gained one s t one we igh t and h a d no compla in t s .

Case 2. Mr. P. B. Act. 55 years. A d m i t t e d to St. Vincen t ' s Hosp i t a l , Dubl in , on 15th ~[ay, 1956, compla in ing o f

d iar rhoea . A g a s t r o e n t e r o s t o m y h a d been. e s t ab l i shed e l sewhere in 1947 for a duo- dena l u lcer wh ich h a d been. act ive for five years . This opera t ion re l ieved his s y m p t o m s for two years , i.e. un t i l 1949. Af t e r t h a t da te , pa in r e t u r n e d a~d go t s tead i ly worse in sp i te o f medica l t r e a t m e n t . I n J a n u a r y , 1956, t he pain d i sappeared , and his appe t i t e improved , b u t a t t he s a m e t i me con t i nuous profuse d ia r rhoea m a d e i ts appearance. In t h e n e x t t h r ee m o n t h s he lost t wo stone, l i e was be lching a g rea t deal and h a d occas ional a t t a c k s o f vomi t ing . On admi s s i on he w a s w a s t e d , anaemic and d e h y d r a t e d . B a r i u m e n e m a s h o w e d a gastro- je junocol ic fistula. (Fig. 2)

His d e h y d r a t i o n was correc ted , t he bowel s ter i l ised and w a s h e d ou t , and opera t ion was p e r f o r m e d on 25th May, 1956.

A t opera t ion a retroeolic g a s t r o - e n t e r o s t o m y was found. The s t o m a c h , af ferent loop o f j e j u n u m and pos ter ior wall o f colon were b o u n d d o w n to one ano the r , w i th a m a r k e d i n f l a m m a t o r y react ion. I t was obvious t h a t the colon, could n o t be s e p a r a t e d off. I t was , therefore , t r a n s e c t e d on. e i ther side of t he i n f l a m m a t o r y mass . The d u o d e n u m was d iv ided and inver ted . The s t o m a c h was cu t across, l e a v i n g a b o u t one- f i f th behind . The j e j u n u m was d iv ided on e i ther side o f t he f is tula a n d the m a s s r e m o v e d en bloc. The c o n t i n u i t y o f colon, a n d j e j t m u m was r e s to red , m~.d t he s t o m a c h a n a s t o m o s e d to t h e j e j u n u m beyor.d t h e po in t w h e i e t he axial a n a s t o m o s i s h a d been pe r fo rmed . T he spec imen is i l lus t ra ted in t he t e x t (Fig. 3).

The p a t i e n t ' s pos tope ra t ive course was sa t i s fac to ry a~d he was d ischarged f rom hosp i ta l t h ree weeks later. W h e n las t s een ( J a n u a r y , 1958) he was back a t h is work , free f r o m s y m p t o m s .

Case 3. Mr. P. B. Act. 40 years.

A d m i t t e d to St. V i ncen t ' s H o s p i t a l , Dubl in , in Septemlcer, 1956. He h a d been

(IASTRO-JEJUNOCOLIC FISTULA 235

F[G. 2 (Cruse No. 2). B a r i u m e n e m a d e m o n - s t r a t e s a g a s t r o j e j u n o -

colic f i s tu la . Fro. 3 (Case No. 2). P h o t o g r a p h of o p e r a t i v e s p e c i m e n v iewed f r o m f r o n t a n d s l i g h t l y to r i g h t . T h e r e sec t ed colon is seen p r a c t i c a l l y end-on . T h e p r o s u m a l , l e junum h a d to be r e s e c t e d ve ry close to t h e f i s tu la as t h e p r e v i o u s e n t e r o s t o m y was e v i d e n t l y of t h e

no-loop t y p e .

a knower, d iabet ic for e ight years . A g ~ s t r o - e n t e r o s t o m y had b e e n e s t ab l i shed else- where for d u o d e n a l u lcer in. 1953. He was well a f te r opera t ion unt i l June,1955, when he deve loped lass i tude which was soon fol lowed by pe r s i s t en t d ia r rhoea , s ix mo t ions a t n i g h t be ing usual . H i s appe t i t e was excel len t , b u t he h a d los t weight . H e had some epigastr ic pain , a ccompan i ed by m a r k e d f la tulence two hou r s a f t e r each meal . Vomi t ing was n o t a fea ture of his compla in t s . He h a d lost 28 lb. we igh t in t he six m o n t h s pr ior to admiss ion . He was th in , d e h y d r a t e d a n d anaemic. H e b a d m a r k e d hal i tosis : b o r b o r y g m i could be hea rd w i t h o u t a s te thoscope . T h e r e was no abdomina l t ende rnes s , no r could a m a s s be pa lpa ted . B a r i u m e n e m a showed a ho ld -up a t the splenic f lexure a n d a possible f is tula could n o t be v i sua l i sed ; on t he con t r a ry , barium. mea l showed a n obvious gas t ro- je junocol ic fistula. This is a reversa l o f t h e usua l radiological f inding in which t he ba r ium e n e m a gives m o r e posi t ive r e su l t s t h a n ba r ium mea l examina t ion .

His d e h y d r a t i o n a n d d iabe tes were cont ro l led , and he was opera ted on 17th October , 1956. A pos te r io r g a s t r o - e n t e r o s t o m y was found , t he pos ter ior wall o f t he colon be i rg a d h e r e n t to t h e ef ferent l imb of the g a s t r o - e n t e r o s t o m y . T h e r e was s o m e local indura t ion a n d in f l ammat ion , b u t a sho r t wide gastro-jejunocolic f is tula could be pal- pa ted . The re was no evidence o f act ive s t e rna l ulcerat ion. In v iew o f t h e pa t i en t ' s poor genera l condi t ion a n d his d iabetes , a two- s t age p rocedure w a s consideIed proper. A t r a n s v e r s e c o l o s t o m y p rox i ma l to t h e f i s tu la was es t ab l i shed and t he a b d o m e n closed. S u b s e q u e n t progress was m o s t sa t i s fac tory , h is d ia r rhoea ceased , a n d his a n a e m i a a n d d e h y d r a t i o n i m p r o v e d rapidly. Six weeks la ter t h e s econd s t age of t he opera t ion was car r ied out. T he pr inciples fol lowed were those a l r eady d i scussed ; t he re was an ac t ive duodena l ulcer p r e sen t i~ add i t ion which compl ica ted t he closure o f t he d u o d e n u m . Th i s u lcer h a d n o t b e e n n o t e d a t t he tixne o f t h e colostor~_y ; it m a y there fore have been due to r eac t iva t i on o f his hype rac id i t y fol lowing subsidence of h is gas t r i t i s .

P o s t o p e r a t i v e p rogress was sa t i s fac tory . H i s colosten, y was closed on. 5 th Januaxy , 1956, and he was d i scharged on 23rd J a n u a r y , 1956, w h e n he was s y m p t o m - f r e e and had gained 12.~ lb. in weight . A l e t t e r rece ived from him. in December , 1957, s t a t e s t ha t he was b a c k a t work in good hea l th , desp i t e his diabetes .

236 IRISH JOURNAL OF MEDICAL SCIENCE

Discussion. These three cases illustrate three degrees of gastro-jejunocolic fistula

and are presented in ascending order of severity of symptoms and com- plexity of treatment. The first, in which symptoms were minimal, had a silent fistula only discovered at operation. The second, in which there were typical symptoms, was in good general health and one-stage re- section was possible. The third, in which symptoms were maximal and diabetes was present, was in such poor condition that a two-stage pro- cedure was considered to be desirable.

The increase in appetite shown by Cases 2 and 3 after the fistula had established itself, has been noted before2 The appetite improves because the stomal ulcer heals and eating is no longer associated with pain. It would seem, from the appetite point of view, that it is better to have faecal gastritis than stomal ulceration.

The association of diabetes and gastro-jejunocolic fistula has not been recorded before; there is, of course, no aetiological connection, but it rendered an already extensive procedure even more hazardous.

Lastly, it was noteworthy that in Lowdon's series of 44 cases collected over the period 1925-1953 there were only two one-stage resections, while in Rhind's series of 5 cases in 1955 all were one-stage resections. This is due, no doubt, to recent advances in antibiotic administration, fluid replacement and anaesthesia, which enable the patient to stand up to the extensive one-stage procedure in a manner which would have been impossible ten years ago.

Summary. A review of gastro-jejunocolic fistulae is presented. The points are

made that the incidence of the condition is on the decline, that it occurs most frequently after posterior gastro-enterostomy and usually in males. The causes of the signs and symptoms are discussed. The possibility of stomal ulcer and gastro-jejunocolic fistula even in the absence of symptoms is noted. Another ease of gastro-jejunocolic fistula in a female is added to the literature. One-stage reseotion, if at all possible, is felt to be the treatment of choice. Three cases are presented, which illustrate three degrees in severity of the condition and three different modes of surgical treatment.

BeSerences.

(1) Bornstein and Wenshel (1941). Surg. Gyn. Obj., 72 : 459. (2) Czerny, Simon and Arnsperger (1903). B6rlin klin. Chit. Suppl. H. 39: 19. (3) Lowdon (1953). Brit, J. Surg. 41: 113. (4) l~Iaingot, R. Abdominal Operations. Lewis, London. (5) Pfoiffer (1941). Surg. Gyn. Obst., 72: 282. (6) Rhind (1955). Lancet, ii. : 1225. (7) Ransome (1945). Surgery, 18 : 177. (8) Skoog-Smith (1950). Surg. Oyn. Obst: 91 : 447. (9) Sandweis (1953). Pepti~ Ulcer. Saunders, Philadelphia.