Delayed Gastrocolic Fistula Following Billroth II Gastrectomy for Ulcer Disease

Excerpt

A 50-year-old man with a history of Billroth II gastrectomy due to peptic ulcer presented to our department with severe weight loss, malnutrition, weakness, and diarrhea. Within the last 4 months, he had experienced a weight loss of almost 30 lbs. Upon admission, the patient’s laboratory data showed severe hypoproteinemia and hypoalbuminemia. A few months earlier, he had been admitted to a psychiatric clinic because of a long history of alcohol and polydrug abuse. Thus, his poor condition had been initially attributed to this as the leading cause of malnutrition. However, despite intensive inpatient treatment with enteral feeding and parenteral nutrition, weight loss and diarrhea continued so that further diagnostic evaluation was initiated. An infectious cause of diarrhea was ruled out. Magnetic resonance imaging (MRI, Fig. 1a) and computed tomography (CT; Fig. 1b) resulted in the suspicion of a gastrocolic fistula (arrows). Upon gastroscopy (Fig. 1c) and colonoscopy, a large gastrojejunocolic fistula was confirmed with a direct view from the stomach (Fig. 1c, *) to the transverse colon (Fig. 1c, #), and surgery was indicated. Intraoperatively (Fig. 1d), a chronic inflammatory process of the proximal jejunum obstructing the physiologic passage was found which had resulted in a severe decrease of the jejunal transit and exacerbated the short bowel syndrome. Adhesions between the stomach, the jejunum, and the transverse colon were removed and stepwise the gastrojejunocolic fistula could be exposed. A combination of a gastric wedge resection with a segmental resection of the colon and the gastrojejunal anastomosis was performed. The digestive tract was reconstructed by re-gastrojejunostomy and colocolostomy. After surgery, the patient recovered well and quickly gained weight by regular oral-enteral nutrition.

…