A case report on multidisciplinary approach towards management of gastrojejunocolic fistula secondary to adenocarcinoma of the colon

Abstract

Introduction

Gastrojejunocolic fistula is an abnormal communication between a portion of the stomach, jejunum and the transverse colon. Gastrojejunocolic (GJC) fistula is an outcome resulting from the surgical procedures of gastrectomy and gastrojejunostomy used to address recurrent peptic ulcer disease and secondary to malignancy. Patients present with the typical symptoms of diarrhea, belching with fecal odor or fecal vomiting and weight loss. Gastrojejunocolic fistula is a rare complication of adenocarcinoma of the colon. En-bloc resection followed by adjuvant chemotherapy helps in managing GJC fistula secondary to adenocarcinoma of colon.

Case resentation:

A 55-year-old male from a rural area presented with a two months history of black stool, vomiting, loose stools, and abdominal pain. He had a history of significant weight loss, chronic alcohol use, and smoking. Investigations revealed anemia, hyponatremia, hypoalbuminemia, and a large exophytic mass on Contrast-Enhanced Computed Tomography (CECT), suggestive of gastrojejunocolic fistula from a carcinoma. Upper gastrointestinal endoscopy showed an ulcero-proliferative growth with high-grade dysplasia. Biochemical tests revealed elevated carcinoembryonic antigen (CEA) levels. The patient underwent surgery for en bloc resection of the stomach, jejunum and transverse colon. Histology confirmed adenocarcinoma of colon with TNM stage IIIC. Post-operative gastrocutaneous fistula was managed conservatively and colostomy reversal was done for prolapse colostomy. He has completed the chemotherapy Capecitabine-Oxaliplatin (CAPOX) regimen. He is doing well and under follow-up for six months post-surgery.

Discussion

Gastrojejunocolic fistula secondary to carcinoma is a rare finding. Gastrojejunocolic fistula originate from the direct spread of the tumor across the gastrocolic omentum or an ulcer in the tumor could trigger an inflammatory peritoneal response, resulting in adhesion and the formation of a fistula.

Conclusion

This case highlights the successful management of a gastrojejunocolic fistula secondary to adenocarcinoma of colon through three stage surgery; diverting stoma, en bloc resection, colostomy reversal surgery along with chemotherapy. Despite post-operative complications, including a gastro-cutaneous fistula and prolapsed colostomy, the patient responded well to treatment. Multidisciplinary approaches and careful monitoring are essential in resource-limited settings for improved patient outcomes.

Highlights

• •Diagnosis and treatment of a gastrojejunocolic fistula secondary to adenocarcinoma of colon.
• •Three-staged surgery followed by adjuvant chemotherapy for optimal outcome.
• •Management of the case was done successfully inspite of the resource limited settings.

Abbreviations

AIDS

acquired immunodeficiency syndrome

AJCC

American Joint Committee on Cancer

BMI

body mass index

CEA

carcinoembryonic antigen

CECT

contrast-enhanced computed tomography

GCF

gastrocolic fistula

GJ

gastrostomy Jejunostomy

GJC

gastrojejunocolic

ICU

intensive care unit

METS

Metabolic Equivalent Score

MUST

Malnutrition Universal Screening Tool

NRI

nutrition risk index

OPD

out patient department

PDS

polydioxanone suture

PEG

percutaneous endoscopic gastrostomy

SCARE

Surgical Care Guidelines

TNM

tumor nodes and metastases

USG

ultrasonography

1. Introduction

Gastrojejunocolic fistula is an abnormal communication between a portion of the stomach, jejunum and the transverse colon. Gastrojejunocolic (GJC) fistula is an infrequent and delayed outcome resulting from the surgical procedures of gastrectomy and gastrojejunostomy used to address recurrent peptic ulcer disease. Generally, GJC fistula is considered to be induced by a stomal ulcer due to inadequate gastric resection, incompleteness of vagotomy and long afferent loop [1,2]. Gastrocolic fistula (GCF) is associated with a variety of diseases, but in recent years it has most frequently been observed with gastric or colonic malignancy [3]. Gastrojejunocolic fistula is a rare complication of adenocarcinoma of the colon [4]. Gastrojejunocolic fistula caused by malignant colonic and gastric disease is rare, and only 30 % of patients present with the typical symptoms: diarrhea, belching with fecal odor or fecal vomiting and weight loss. Other symptoms being gastrointestinal bleeding, abdominal pain [5,6]. Laboratory testing and physical examination in case of malignant GJC fistula show electrolyte imbalances and severe malnutrition, with some patients even appearing cachexic [3]. A variety of other causes of gastrocolic fistula have been reported, these include syphilis, tuberculosis, abdominal trauma, Crohn's disease, cytomegalovirus gastric infection in Acquired Immunodeficiency Syndrome (AIDS) patients and percutaneous endoscopic gastrostomy (PEG) tubes [7]. Surgery is one of the curative treatments for GJC fistula.

In this case report we describe a patient who presented with black coloured stool, vomiting, diarrhea and abdominal pain to our tertiary academic medical center and how we managed the case with a multidisciplinary approach. We present the following case in accordance with Surgical Care Report (SCARE) guidelines and have provided a completed checklist [8].

2. Case presentation

A 55- years old male from a rural municipality was presented to the Out Patient Department (OPD) of our hospital with a history of black coloured stool for two months, vomiting for one month, loose stool for one month and abdominal pain for one month. He developed black coloured stool two months back which was insidious in onset and progressive in nature. He also had complaints of vomiting, two to three episodes per day after nauseating for ten to fifteen minutes after taking food. Vomitus was feculent and foul smelling, about 50 ml in amount with no bile or blood stained. He complained of loose stools, one to two episodes per day after each feed, stool contains undigested food particles. The patient also developed pain in the abdomen which was gradual on onset, over epigastric region, radiating to back, dull aching and severe enough to hamper his daily activities. Pain was relieved after vomiting and passage of stool and aggravated by food. There is a history of significant weight loss of about 10 kgs in three months.

Patient gave history of hospital admission two years ago at the other center with symptoms of generalized weakness and vomiting with blood. An upper gastrointestinal endoscopy was conducted where the biopsy was not taken, revealing normal findings. Despite the normal endoscopy results, the patient was diagnosed as anemia and was hospitalized for three days in the Intensive Care Unit (ICU) as the level of hemoglobin dropped to 3.8 mg/dl. Two pints of blood were transfused and the patient was discharged after attaining hemodynamic stability.

Patient consumed around 250 ml of alcohol per day for the last four years and was also a chronic smoker for 35 years with a pack year of 8.8. There was no history of fever, cough, water brash, no abdominal distention, no yellowish discolouration of skin, no bleeding from other sites, no burning micturition, no blood in urine.

Upon examination, the patient was cachetic with body mass index (BMI) being 17kg/m² and there was presence of pallor over lower palpebral conjunctiva. Other assessment tools were used pertaining to the following findings: Malnutrition universal screening tool (MUST) = 3, Nutrition risk index (NRI) = 74.645 suggestive of severe malnutrition andMetabolic Equivalent Score (METS) = 3 suggestive of poor functional status.

On investigation, hemoglobin was 9.2 g/dl (14–18 g/dl) [9], Hyponatremia, Sodium level was 128 mEq/l (135-145 mEq/l) [10], Hypoalbuminemia, Serum albumin level was 2.0 g/dl (3.5–5 g/dl) [11].

Ultrasonography (USG) of abdomen and pelvis showed an irregular and circumferential wall thickening (19.7 mm) at the region of body of stomach associated with adjacent increased echogenicity and few adjacent peri-gastric lymph nodes (one measuring 6.1 × 7.7 mm) which required further evaluation for which Contrast-Enhanced Computed Tomography (CECT) of abdomen, pelvis and chest was done.

CECT abdomen and pelvis with oral contrast showed a large exophytic mass of size 7.2 × 7.2 cm arising from greater curvature of the body of the stomach. The lesion was abutting the distal end of transverse colon with loss of fat plane in between. The lesion was infiltrating the proximal jejunum with formation of fistulous tract of length of 3.8 × 0.8 cm (Fig. 1). There was presence of air attenuation foci within the lesion. There were no areas of calcifications within the lesion. Post contrast study showed marked heterogenous peripheral enhancement of lesions. There were few lymph nodes adjacent to the lesion, largest measuring 12x11mm. These findings suggested gastrojejunocolic fistula secondary to malignancy.

Fig. 1.

Coronal section of CT scan image with oral contrast. A large exophytic mass arising from greater curvature of the body of the stomach was infiltrating the proximal jejunum with formation of fistulous tract (black arrow) suggested gastrojejunocolic fistula and another fistulous tract infiltrating distal transverse colon; splenic flexure (green arrow) suggesting of gastrojejunocolic fistula. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Upper gastrointestinal (GI) endoscopy revealed a single cratered, irregularly shaped ulcero-proliferative growth in greater curvature with pus like secretion from growth without any bleeding and eight biopsy samples were taken and was sent for oncological evaluation which was suggestive of high-grade dysplasia. Biochemical test for tumor marker showed marked increase in carcinoembryonic antigen (CEA) i.e. 194.30 ng/ml normal value being <2.9 ng/ml [12].

Provisional diagnosis was gastrojejunocolic fistula secondary to carcinoma of stomach.

So, the patient was admitted for optimization of nutrition and anemia. Total parenteral nutrition was given for seven days as per calorie requirement. After correction of hematocrit, first stage surgery was performed in which diverting colostomy proximal to gastrojejunocolic fistula and feeding jejunostomy was placed. Intraoperative biopsy from the greater curvature mass was done, which came out to be adenocarcinoma. Initially the patient was planned for chemotherapy for locally advanced carcinoma of stomach but the patient refused to undergo chemotherapy. Patient functional status was not improving and had persistent upper GI bleeding. So, en bloc resection of distal stomach, part of transverse colon and jejunum was performed as second staged surgery.

2.1. Operative findings

Stomach was hugely dilated with large intraluminal mass of size approximately 10x10cm at the greater curvature of the stomach that was creating the controlled fistula with proximal part of jejunum and the mid part of transverse colon, first part of duodenum was normal and the mass was adherent to proximal jejunum.

2.2. Per operative procedure

On exploratory laparotomy, there were no ascites, no peritoneal dissemination and no liver metastases. So, enbloc resection of distal stomach, part of transverse colon and jejunum was performed. Only segmental resection of colon was done in this case as our preliminary diagnosis was Gastric cancer for which only D1 Gastric lymph node dissection was only done. Ends of resected jejunum was used to create Roux en Y Gastrojejunostomy as shown illustrative diagram below (Fig. 2, Fig. 3, Fig. 4).

Fig. 2.

Specimen from an en bloc resection of the distal stomach, part of the jejunum, and the colon with an internal fistula.

Fig. 3.

Fistulous tract in resected specimen of the stomach.

Fig. 4.

Schematic diagram; (A) malignant gastrojejunocolic fistula. (B) Stage I - feeding jejunostomy with proximal colostomy. (C) Stage II – reconstruction after enbloc resection- Roux en Y antecolic gastrojejunostomy with intact feeding jejunostomy and diverting loop colostomy of first stage surgery.

Transected parts were sent for oncological evaluation (Fig. 5); Tumor site was transverse colon. Greatest dimension being nine cm and additional dimensions 8x4cm. Histological type being adenocarcinoma. Histologic grade G1: well-differentiated. TNM classification: T4N1MX (Fig. 6); Tumor directly invaded or adhered to adjacent organs or structures, no regional lymph nodes were positive, but there were tumor deposits in the subserosa, mesentery, or non peritonealized pericolic, or perirectal/mesorectal tissues. Distant metastasis could not be assessed. American Joint Committee on Cancer (AJCC) 8th edition staging IIIC [13].

Fig. 5.

Gross specimen showing a communication between stomach, colon and jejunum.

Fig. 6.

Thickened margin with grey white lesion suggesting the tumor site in transverse colon which adheres to adjacent organs.

After en bloc resection surgery the patient was discharged on 12^th post operative day. He was again admitted on 18^th postoperative day due to gastrocutaneous fistula which was managed with Nil Per Oral, pantoprazole, IV fluids and feeding jejunostomy. This was resolved in two weeks. The Capox regimen was started for chemotherapy. It includes the drugs capecitabine and oxaliplatin. During that period, patient presented with features on intestinal obstruction due to prolapsed transverse colostomy. Prolapses colostomy was resected and side to side colo-colic anastomosis was done to restore the intestinal continuity. Actually, the stoma reversal was planned on elective basis but he presented earlier in emergency for which anastomosis was performed earlier. (Fig. 4). The chemotherapy was again resumed. He completed this in six cycles. Now the patient is doing well for six months and he is under follow-up. The timeline of the patient from the presentation to the treatment is shown in Fig. 7.

Fig. 7.

Timeline of the patient from the presentation to the treatment.

3. Discussion

Gastrojejunocolic fistula is a late complication after gastrojejunostomy for peptic ulcer or malignant gastrointestinal diseases [14,15]. This fistula occurs due to inadequate gastrectomy, simple gastroenterostomy, or inadequate vagotomy [16]. In western world, the most common cause of gastrocolic fistula is transverse colon adenocarcinoma, with a reported incidence of 0.3–0.4 % in operated cases, while gastric cancer is the most frequent cause in eastern countries [17]. Adenocarcinoma is seen as an irregular mucosal or polypoidal growth, with or without intestinal obstruction, and is commonly associated with lymphadenopathy, metastases, or ascites. Upon additional examination and analysis of deeper tissue samples, the histopathological report revealed the presence of adenocarcinoma. Two theories have been suggested to explain the occurrence of Gastrojejunocolic (GJC) fistulas associated with malignancy: one states that cancerous gastrocolic fistulas originate from the direct spread of the tumor across the gastrocolic omentum, while another theory suggests that an ulcer in the tumor could trigger an inflammatory peritoneal response, resulting in adhesion and the formation of a fistula [4].

A patient of GJC fistula presents with typical symptoms of diarrhea and weight loss. Marshall and Knud-Hansen reported that both these symptoms were present in 80 % and 82 % of patients [15]. Diarrhea, fecal vomiting, and weight loss make up the characteristic triad of clinical features associated with GCF. With a longer course, there may be other clinical symptoms such as malnutrition, weight loss, anemia, and hypoproteinemia, which may be accompanied by leukocytosis and electrolyte imbalances [3]. Diarrhea experienced in gastrojejunocolic fistula is a result of reflux of colonic contents into the upper gastro-intestinal tract, rather than reflux of gastric contents into the large bowel [18].

Malnutrition is prevalent, especially among patients with gastrojejunocolic fistula. This sort of patient has malnutrition due to reflux of feculent material to the stomach and jejunum which causes electrolyte imbalance and other reasons being bypassing of absorptive surface area. Derangement of small intestine function is probably the result of damage to intestinal mucosa caused by the passage of colonic contents through the small intestine [19].

So, placing Feeding Jejunostomy distal to Gastrojejunocolic fistula to utilize bypassed jejunum by fistula and diverting the stoma prevents reflux and contamination of gastric content which prevents feculent odor and improves nutrition status of patient. Malnourished patients who undergo operation have an increased likelihood of perioperative morbidity and mortality. The performance of a nutritional assessment aids in the recognition of such patients and provide a risk assessment profile [20]. In the late 1930s, a three-stage surgical approach, involving colostomy, fistula resection, and subsequent colostomy closure, was established [21]. However, this method had a drawback as it had three major surgical interventions for each patient. Lahey introduced a more efficient two-stage procedure, a proximal defunctionalized ileosigmoidostomy, followed by fistula resection, subtotal gastrectomy, and colectomy [16]. Lahey's approach significantly lowered mortality and morbidity rates in patients with gastrojejunocolic (GJC) fistula, becoming widely accepted as the preferred treatment. More recently, advancements in parenteral or enteral nutrition support, along with improvements in intensive care, have led to the acceptance of a one-stage en bloc resection as the procedure of choice, resulting in decreased mortality and morbidity associated with GJC fistula [21,22]. In our case, first we performed three-stage approach. The optimal approach for addressing malignant gastrocolic fistulas (GCFs) remains radical resection, involving the en-bloc removal of the affected gastrocolic region and suturing of the remaining sides of the fistula. Depending on individual circumstances, reconstructive measures or the implementation of a temporary diverting colostomy may be considered [23]. En-bloc resection followed by adjuvant chemotherapy can result in long term survival of patient with GJC fistula secondary to adenocarcinoma [3].

Some of the learnings we can take are that the patient was anemic and had gastrointestinal bleeding. Both upper and lower GI endoscopy was a must. Colonoscopy was not done in our case otherwise the diagnosis would have been made earlier. Since. the patients of such cases are malnourished, nutritional optimization prior to definitive resection is essential.

4. Conclusion

The case highlights the challenges in diagnosing complex gastrointestinal malignancies in resource-limited settings and emphasizes the importance of a multidisciplinary approach. It serves as a testament to the intricacies of managing advanced gastrointestinal tumors in challenging clinical environments. This case report aims to contribute to the medical literature by explaining the diagnostic and therapeutic nuances encountered in the management of malignant gastrojejunocolic fistula.

Patient consent

Written informed consent was obtained from the patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

As this is a case report, ethical approval from the Kathmandu University School of Medical Sciences – Institutional Review Committee (KUSMS-IRC) is not mandatory but consent from the patient is necessary which is available. Patient anonymity is maintained throughout this manuscript, and consent was obtained for publication from the patient. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Funding

No sources of funding.

Author contribution

Sayara Mainali: literature review, manuscript preparation and proof reading.

Aditya Kumar Jha: literature review, manuscript preparation and proof reading.

Suraj Keshari: radiological findings interpretation and proof reading.

Arun Gnyawali: concept, manuscript preparation, edit and review.

Uttam Laudari: concept, supervision, literature review, manuscript preparation, edit and review.

Bala Ram Malla: supervision, manuscript preparation, edit and review.

Guarantor

Bala Ram Malla, B. Malla, General Surgeon, Department of Surgery, Kathmandu University School of Medical Sciences, Dhulikhel, 45210, Nepal.

Email: mallabr504@dhulikhelhospital.org.

Research registration number

NA.

Declaration of competing interest

The authors declare no conflicts of interest.