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Free perforation of a gastrocolic fistula
CASE REPORTS
Free Perforation of a Gastrocolic Fistula R. GER, MD, FACS, Bronx, New York H. ADLER, MD, Bronx, New York R. G. BERNSTEIN, MD, Bronx, New York
Gastrocolic fistula complicating benign gastric ulcer is a rarity, and by 1968 only thirty-seven cases had been reported [I]. No case of free perforation of a gastrocolic fistula appears to have been reported. Case Report A fifty-eight year old woman was admitted to the hospital because of attacks of diarrhea over a period of five months. There was no blood or mucus in the stool, but there were accompanying abdominal pains. Intermittent vomiting occurred but the vomitus did not contain feces. There was a weight loss of 30 pounds over the past three months. Her past history included rheumatoid arthritis for thirty years for which she had been taking steroids over the last twenty years. Ten years previously a diagnosis of peptic ulcer was established, further details of which could not be obtained. She had been treated medically for this lesion with apparent success. The patient underwent radiologic investigation by means of an upper gastrointestinal series which showed a gastrocolic fistula. (Figure 1.) Physical examination showed an obese, dehydrated patient who had lost a considerable amount of weight. There were marked deformities in all extremities, the result of rheumatoid arthritis. A sacral decubitus ulcer was present. There were no abnormal physical signs in the abdomen. Chest roentgenogram showed arthritic changes in both shoulder joints. Laboratory data were as follows: hemoglobin 9.29 gm per cent, erythrocyte sedimentation rate 118 mm per hour, albuminuria, serum glutamic oxalacetic transaminase 115 units, albumin 2.4 gm per cent, total protein 6.1. The patient was being prepared for surgery when three days after admission severe epigastric pain, hypotension, and signs of generalized peritonitis developed. A diagnosis of perforation of the gastrocolic fistula was made and the patient was submitted to emergency surgery. At operation, a right paramedian incision was made. A mass was present which included the pyloric portion of the stomach, a portion of the proximal transverse colon, and the omentum. There was surrounding turbid fluid which contained a moderate quantity of fecal maFrom the Departments of Einstein College of Medicine,
Volume
122,
July
1971
Surgery. Bronx,
Medicine, New York.
and
Radiology,
Albert
terial. A perforation of the fistulous track could be seen clearly. The gallbladder contained multiple calculi. The fistula was divided and the defect in the transverse colon closed in two layers. Partial gastrectomy was carried out with a gastrojejunal anastomosis as well as cholecystectomy. The operative area was irrigated with neomycin solution, and drains were passed down to the site of the colonic closure and to the gallbladder bed. Culture of the peritoneal fluid revealed Escherichia coli, Streptococcus viridans, and a yeast-like organism. The administration of steroids which had been increased for the operative procedure was maintained in the postoperative period and gradually reduced to the patient’s normal level. Except for a delay in the healing of the sacral decubitus lesion, the patient had an uneventful recovery. The pathology report indicated a chronic pyloric ulcer with perforation and localized acute peritonitis (portion of stomach), chronic cholecystitis with cholelithiasis, and peritonitis.
Figure 1. Upper gastrointestinal series demonstrates a gastrocolic fistula due to a large gastric ulceration (arrow). The communication from the stomach is to the transverse colon.
115
Ger, Adler,
and
Bernstein
Comments
It is noteworthy that a review of the literature since 1920 shows that of the twelve reported cases of gastrocolic fistula, four patients had rheumatoid arthritis for which they were being treated with steroids [I]. This additional case report strengthens the suspicion that the occurrence of this uncommon complication is related to coexistent rheumatoid arthritis and steroid administration. Most surgeons agree that the optimal treatment of a gastrocolic fistula is resection of the fistula together with partial gastrectomy and colectomy. Certainly, those patients treated more conservatively did not fare well. There appears to be no previous experience in the management of a perforated gastrocolic fistula, but the successful handling of the present case would suggest that the same operative approach be recommended. The alternative treatment is to close the perforation with or without an omental seal and carry out a definitive operation after recovery. In keeping with the current trend in the approach to a perforated duodenal ulcer [2], a primary definitive operation is suggested as a more logical approach. It is difficult, from the standpoint of both general surgical principles and our experience with this patient, to understand the necessity for performing colectomy and for interposing a portion of the omentum between the colon and the stomach as advised by Lewis, Levick, and Gazzaniga [3]. In this patient, the defect in the colon was merely
116
closed in two layers with a good result and no attempt was made to interpose omenturn between the colon and stomach. A formal colectomy with an anastomosis must add to the severity of the operation and to a higher morbidity and mortality. Excision of a gastric ulcer by partial gastrectomy in the absence of a Zollinger-Ellison tumor is rarely followed by local recurrence and even more rarely by fistulization. The recurrence of a gastrocolic fistula once excised as just described must be extremely rare and we could not find any evidence to support the contention of Lewis, Levick, and Gazzaniga [3] that interposition of omentum is a necessary step in the operation to prevent recurrence of the gastrocolic fistula. Summary
A case is recorded of free perforation of a gastrocolic fistula in a patient with rheumatoid arthritis for which steroid therapy was being given. There does not appear to be a previously documented case report. The management of this patient is briefly described. References 1. Sterns EE, Bird CE: Benign gastric ulcer a,nd gastrocolic fistula. Canad J Surg 11: 199, 1968. 2. Eisenberg MM: What’s new in gastrointestinal surgery1969. J Surg Res 7: 337, 1970. 3. Lewis MI, Levick AD, Gazzaniga DA: Gastrocolic fistula secondary to benign gastric ulcer. Dis Colon Rectum 9: 348, 1966.
The American
Journal
of Surges
Free Perforation of a Gastrocolic Fistula R. GER, MD, FACS, Bronx, New York H. ADLER, MD, Bronx, New York R. G. BERNSTEIN, MD, Bronx, New York
Gastrocolic fistula complicating benign gastric ulcer is a rarity, and by 1968 only thirty-seven cases had been reported [I]. No case of free perforation of a gastrocolic fistula appears to have been reported. Case Report A fifty-eight year old woman was admitted to the hospital because of attacks of diarrhea over a period of five months. There was no blood or mucus in the stool, but there were accompanying abdominal pains. Intermittent vomiting occurred but the vomitus did not contain feces. There was a weight loss of 30 pounds over the past three months. Her past history included rheumatoid arthritis for thirty years for which she had been taking steroids over the last twenty years. Ten years previously a diagnosis of peptic ulcer was established, further details of which could not be obtained. She had been treated medically for this lesion with apparent success. The patient underwent radiologic investigation by means of an upper gastrointestinal series which showed a gastrocolic fistula. (Figure 1.) Physical examination showed an obese, dehydrated patient who had lost a considerable amount of weight. There were marked deformities in all extremities, the result of rheumatoid arthritis. A sacral decubitus ulcer was present. There were no abnormal physical signs in the abdomen. Chest roentgenogram showed arthritic changes in both shoulder joints. Laboratory data were as follows: hemoglobin 9.29 gm per cent, erythrocyte sedimentation rate 118 mm per hour, albuminuria, serum glutamic oxalacetic transaminase 115 units, albumin 2.4 gm per cent, total protein 6.1. The patient was being prepared for surgery when three days after admission severe epigastric pain, hypotension, and signs of generalized peritonitis developed. A diagnosis of perforation of the gastrocolic fistula was made and the patient was submitted to emergency surgery. At operation, a right paramedian incision was made. A mass was present which included the pyloric portion of the stomach, a portion of the proximal transverse colon, and the omentum. There was surrounding turbid fluid which contained a moderate quantity of fecal maFrom the Departments of Einstein College of Medicine,
Volume
122,
July
1971
Surgery. Bronx,
Medicine, New York.
and
Radiology,
Albert
terial. A perforation of the fistulous track could be seen clearly. The gallbladder contained multiple calculi. The fistula was divided and the defect in the transverse colon closed in two layers. Partial gastrectomy was carried out with a gastrojejunal anastomosis as well as cholecystectomy. The operative area was irrigated with neomycin solution, and drains were passed down to the site of the colonic closure and to the gallbladder bed. Culture of the peritoneal fluid revealed Escherichia coli, Streptococcus viridans, and a yeast-like organism. The administration of steroids which had been increased for the operative procedure was maintained in the postoperative period and gradually reduced to the patient’s normal level. Except for a delay in the healing of the sacral decubitus lesion, the patient had an uneventful recovery. The pathology report indicated a chronic pyloric ulcer with perforation and localized acute peritonitis (portion of stomach), chronic cholecystitis with cholelithiasis, and peritonitis.
Figure 1. Upper gastrointestinal series demonstrates a gastrocolic fistula due to a large gastric ulceration (arrow). The communication from the stomach is to the transverse colon.
115
Ger, Adler,
and
Bernstein
Comments
It is noteworthy that a review of the literature since 1920 shows that of the twelve reported cases of gastrocolic fistula, four patients had rheumatoid arthritis for which they were being treated with steroids [I]. This additional case report strengthens the suspicion that the occurrence of this uncommon complication is related to coexistent rheumatoid arthritis and steroid administration. Most surgeons agree that the optimal treatment of a gastrocolic fistula is resection of the fistula together with partial gastrectomy and colectomy. Certainly, those patients treated more conservatively did not fare well. There appears to be no previous experience in the management of a perforated gastrocolic fistula, but the successful handling of the present case would suggest that the same operative approach be recommended. The alternative treatment is to close the perforation with or without an omental seal and carry out a definitive operation after recovery. In keeping with the current trend in the approach to a perforated duodenal ulcer [2], a primary definitive operation is suggested as a more logical approach. It is difficult, from the standpoint of both general surgical principles and our experience with this patient, to understand the necessity for performing colectomy and for interposing a portion of the omentum between the colon and the stomach as advised by Lewis, Levick, and Gazzaniga [3]. In this patient, the defect in the colon was merely
116
closed in two layers with a good result and no attempt was made to interpose omenturn between the colon and stomach. A formal colectomy with an anastomosis must add to the severity of the operation and to a higher morbidity and mortality. Excision of a gastric ulcer by partial gastrectomy in the absence of a Zollinger-Ellison tumor is rarely followed by local recurrence and even more rarely by fistulization. The recurrence of a gastrocolic fistula once excised as just described must be extremely rare and we could not find any evidence to support the contention of Lewis, Levick, and Gazzaniga [3] that interposition of omentum is a necessary step in the operation to prevent recurrence of the gastrocolic fistula. Summary
A case is recorded of free perforation of a gastrocolic fistula in a patient with rheumatoid arthritis for which steroid therapy was being given. There does not appear to be a previously documented case report. The management of this patient is briefly described. References 1. Sterns EE, Bird CE: Benign gastric ulcer a,nd gastrocolic fistula. Canad J Surg 11: 199, 1968. 2. Eisenberg MM: What’s new in gastrointestinal surgery1969. J Surg Res 7: 337, 1970. 3. Lewis MI, Levick AD, Gazzaniga DA: Gastrocolic fistula secondary to benign gastric ulcer. Dis Colon Rectum 9: 348, 1966.
The American
Journal
of Surges