Received: 25 February 2017 Accepted: 24 May 2017

DOI: 10.1002/aid2.13096

CASE REPORT

A rare case of gastrocolic fistula caused by benign gastric ulcer

Tzu-Chan Hong | Ming-Shiang Wu | Jyh-Ming Liou

Department of Internal Medicine, National Taiwan

University Hospital, Taipei, Taiwan
Correspondence
Jyh-Ming Liou, Department of Internal Medicine
and Primary Care Medicine, National Taiwan
University Hospital, National Taiwan University,
College of Medicine, Number 7, Zhongshan South
Road, Zhongzheng District, Taipei City 10002,
Taiwan.
Email: jyhmingliou@gmail.com
Gastrocolic fistula is recognized as a rare complication of malignancy or benign
disease. The authors presented a case of an 84-year-old woman who had epigastric
pain, feculence vomiting, and diarrhea soon after a meal after taking nonsteroidal
anti-inflammatory drugs (NSAIDs) for a year. Gastrocolic fistula was suspected
under esophagogastroduodenoscopy (EGD) and confirmed by post-barium meal-
computed tomography (CT) scan. However, the patient declined surgery and
received medical treatment alone. She died of sepsis 1 month later. Gastrocolic fis-
tula may be associated with anemia, malnutrition, and electrolytes imbalance in
addition to the symptoms presented above. In summary, gastrocolic fistula should
be considered in patients taking long-term NSAIDs. Diagnostic tools includes stan-
dard barium enema, barium meal, upper and lower gastrointestinal endoscopy, and
CT scan. Treatment options include surgery, medical treatment, or endoscopic
interventions. However, the prognosis of gastrocolic fistula is poor without surgical
management.

KEYWORDS

feculent vomiting, gastric ulcer, gastrocolic fistula

1 | INTRODUCTION this admission when intermittent epigastric pain developed.

Gastrocolic fistula is a pathological connection between the
stomach and the colon. It was first described by Haller in
1755 as a complication of gastric cancer. However, benign
conditions caused by gastric ulcer and also malignancy,
including gastric cancer and colon cancer, can all cause the
formation of fistula. Due to its poor prognosis despite surgi-
cal and medical treatment, early recognition of its presenta-
tion is important. The most popular diagnostic method is
barium enema; however, we demonstrated the diagnostic
images of both esophagogastroduodenoscopy and barium
meal computed tomography (CT) in this case.
2 | CA S E R E P O R T
An 84-year-old woman was admitted to the hospital because
of vomiting and diarrhea for 1 week. The patient had been in
her usual state of health until approximately 3 months before
The pain was dull in character. It was aggravated after food
ingestion and relieved after taking an antacid. The pain
sometimes woke her up in the middle of the night. She also
had an unintentional weight loss of more than 6 kg over the
past 3 months, but she denied passage of tarry or black
stools. She frequently took NSAIDs for her low back pain in
the preceding year. One week before this admission, she suf-
fered from vomiting and general malaise. The vomitus was
foul in odor and looked like fecal material. Besides this, she
also developed diarrhea soon after a meal in the most recent
week. She was brought to the hospital due to aggravation of
her symptoms and a fever of up to 38.6 C for one day.
On examination, she appeared cachectic and acutely ill-
looking. Her temperature was 38.6 C, the pulse rate was
86 beats per minute, and blood pressure was 142/84 mm
Hg. Her conjunctiva was pale. Her neck was supple without
lymphadenopathy. The chest expanded symmetrically, and
the breath sounds were clear. The bowel sound was nor-
moactive, and the abdomen was flat and soft. Mild

© 2018 The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver
142 wileyonlinelibrary.com/journal/aid2 Adv Dig Med. 2018;5:142–144.
HONG ET AL.
tenderness was noted at the epigastric region, but there was
no rebound tenderness. Hemogram showed leukocytosis
(white blood cell count 21 100/μL) and normocytic anemia
(hemoglobin 8.8 g/dL). Her C-reactive protein was elevated
(8.6 mg/dL). Urine analysis demonstrated no bacteriuria or
pyuria. An esophagogastroduodenoscopy (EGD) indicated a
large amount of semiformed feces over the greater curvature
of the corpus and fundus of the stomach (Figure 1A). After
irrigation and removal of some fecal materials, a huge ulcer
was identified (Figure 1B, retroflex view). During the exam-
ination, air bubbles appeared on a volcano-like area
(Figure 1B, arrow) at the ulcer crater, indicating a communi-
cation of the gastric ulcer with another hollow organ. CT of
the abdomen showed the passage of barium from the stom-
ach into the colon directly through a fistula (arrow) soon
after ingestion of the barium meal (Figure 2A and 2B).
Pathology of the gastric biopsy from the ulcer margin and
crater demonstrated no malignant cells. Treatment with a
proton-pump inhibitor, antibiotics, and total parenteral nutri-
tion were begun immediately. The patient declined surgical
intervention. Intravenous ampicillin/sulbactam was given to
cover intraabdominal infection, and her fever subsided after
the empirical treatment. The blood cultures for bacterial and
fungus were negative. Then, we switched the antibiotic to
piperacillin/tazobactam to cover nosocomial pathogens due
to recurrent fever. However, her fever persisted, and flucona-
zole was added to cover catheter-related fungal infection.
Finally, the patient died of sepsis 1 month later.
3 | DISCUSSION
Feculent vomiting usually presents in patients with intestinal
obstruction, gastrocolic fistula, or coprophagy. Gastrocolic
fistula is a rare complication of benign or malignant disease
and may also be iatrogenic. Earlier case series showed that a
substantial proportion (50%-65%) was attributed to benign
FIGURE 1 Endoscopic findings. A, an esophagogastroduodenoscopy demonstrated a large amount of semiformed feces over the greater curvature of the
corpus and fundus of the stomach. B, after irrigation and removal of some fecal materials, a huge ulcer was identified (retroflex view). During the
examination, air bubbles appeared on a volcano-like area (long arrow) at the ulcer crater, indicating a communication of the gastric ulcer with another hollow
organ
143
disease, and about 50% to 75% were associated with the use
of anti-inflammatory drugs, including aspirin, NSAIDs, or
steroids, prior to the development of fistula, which more
commonly appeared in middle-aged women.1,2 Benign
causes also include syphilis, tuberculosis, abdominal trauma,
Crohn's disease, or cytomegalovirus gastric infection in
acquired immune deficiency syndrome patients. The place-
ment of percutaneous endoscopic gastrostomy tubes was
reported as an iatrogenic cause of the disease.3 Malignant
causes were gastric cancer predominant in Eastern countries
and transverse colon cancer in Western countries. Other
malignancies reported as the cause of gastrocolic fistula were
lymphoma, carcinoid tumors, metastatic tumors, infiltrative
tumors of the pancreas, and duodenal or biliary tract.4
The initial presented symptoms are diarrhea, fecal vomit-
ing, and epigastric pain. Weight loss, malnutrition, anemia,
vitamin insufficiency, electrolyte imbalance, and sepsis
appear later in the disease course. To make a diagnosis, the
most commonly used barium edema has a better diagnostic
yield rate (visualize in 90%-100% of cases) than barium meal
(27%-70%) because the intraluminal pressure generated dur-
ing the procedure is greater in the colon.4,5 Gastroscopy and
colonoscopy may also be used for diagnosis if the fistula is
easy to visualize despite gastric folds and haustra, as in our
case. CT scan soon after barium meal, as demonstrated in this
case, is also helpful in detecting the fistula. Both endoscopy
and CT can also detect fistula secondary to malignancy, and
biopsy can be taken for pathology from endoscopy.5
Surgery remains the mainstay treatment of gastrocolic fis-
tula. The reported prognosis was poor. Surgical methods,
including staged or single-stage radical en-bloc resection, are
tailored to individualize the condition of the patients and char-
acteristics of the fistula.4,5 In patients with benign gastrocolic
fistula without peritoneal sign, the attempts of conservative
medical treatment may be tried with parenteral nutrition sup-
port, acid-suppressive therapy, and discontinuing ulcerogenic
medication. Novel attempts were tried with success, including
144
FIGURE 2 Findings of computed tomography (CT). CT of the abdomen showed passage of barium from the stomach into the colon directly through a
fistula (short arrow, 2A and 2B) soon after ingestion of the barium meal
endoscopic closure of fistula by a cardiac septal defect closure
device,6 direct clipping,7 placement of colonic stent,8 or the
wire-guided simultaneously dual scope approach.9 However,
only few case reports have tried these developing techniques
recently. We have assessed the feasibility of endoscopic ther-
apy. However, we found that it was not possible to close the
fistula by endoscopy in this case due to the chronic large and
deep ulcer. The development of novel endoscopic devices is
warranted.
In summary, we demonstrated a case of gastrocolic
fistula caused by NSAIDs presenting with feculent vomiting,
epigastric pain, and weight loss in this report. Through the
concomitant use of gastroscopy and barium meal CT,
the fistula was identified, and evaluation of malignancy was
also achieved. However, due to the patient's personal prefer-
ence of not receiving surgery considering its benign nature
and old age, only supportive care was given. Gastrocolic
fistula should be considered in patients with feculent vomit-
ing containing formed or semiformed feces. The diagnostic
approach was preferred with barium enema but also
achieved by endoscopy and CT. Treatment options include
surgery, medical treatment, or endoscopic interventions.
However, the prognosis of gastrocolic fistula is poor without
surgical management.
CONFLICTS OF IN TER EST
The authors declare no conflict of interest.
HONG ET AL.
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How to cite this article: Hong T-C, Wu M-S,
Liou J-M. A rare case of gastrocolic fistula caused by
benign gastric ulcer. Adv Dig Med. 2018;5:142–144.
https://doi.org/10.1002/aid2.13096