Chronic diarrhoea in an elderly woman: a challenging maze

Introduction

An 84-year-old woman was hospitalised with a 1-year history of aqueous diarrhoea, with 10–15 episodes a day, particularly during daytime and after meals. She also mentioned anorexia, weight loss (20% of body weight) and epigastric discomfort. There was no history of fever, vomiting or blood or mucus in the stools. She had a history of multiple surgical interventions, including a Nissen fundoplication, a left hemicolectomy due to diverticular disease, a gastrojejunostomy with adhesiolysis due to intestinal subocclusion and a cholecystectomy, the last one 6 years before. She had an extensive outpatient investigation with negative microbiological stool tests, including Clostridium difficile, normal faecal calprotectin and elastase, normal thyroid function, negative coeliac antibodies and no vitamin or nutrient deficiency. Radiological assessment, including CT and magnetic resonance enterography, showed small bowel and left colon distension, without signs of complications. A colonoscopy, performed 7 months before hospital admission, revealed erythema of the distal colon and rectum, with biopsies showing a subtle chronic inflammatory infiltrate, and a colo-colonic anastomosis 45 cm from the anal verge. During hospitalisation, she had an upper gastrointestinal endoscopy (figure 1A,B, submitted in colour as online supplemental material) and a barium study (figure 2) performed.

Figure 1.

Upper gastrointestinal endoscopy.

Figure 2.

Barium study.

Question

What is the diagnosis?

Answer

Upper gastrointestinal endoscopy revealed an ulcerated surgical anastomosis (figure 1A) at the posterior face of the body/antrum transition, with two identifiable lumens: one leading to the jejunum (gastrojejunal anastomosis) with normal mucosa, and a second lumen with adherent faecal content (figure 1B). A barium study revealed passage of contrast from the gastric body to the descendent colon (figure 2), in relation with a gastrocolic fistula (GCF). After a multidisciplinary discussion, the patient underwent subtotal gastrectomy and segmentary resection of the previous gastrojejunostomy with fistula excision. Histopathology report revealed focal erosion of gastric mucosa and proximal bowel, with inflammatory infiltrate and granulation tissue, compatible with dehiscence of the gastrojejunal anastomosis, without evidence of malignancy. At follow-up, the patient was asymptomatic.

A GCF is an abnormal communication between the stomach and the colon, most commonly due to neoplastic invasion, but also iatrogenic, following surgery or gastrostomy tube migration.¹ The incidence of iatrogenic GCF is unknown, with few case reports predominantly related to bariatric surgery.² The best diagnostic tool is a barium study.³ Endoscopy is mandatory to exclude malignancy, despite easily missing the fistula.⁴ The best treatment approach is surgery, with less invasive treatments, such as an over-the-scope-clip, emerging for selected cases.^{1 3}

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

Not applicable.