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Ann Med Surg (Lond)
Ann Med Surg (Lond)
MS9
Annals of Medicine and Surgery
2049-0801
Lippincott Williams & Wilkins Hagerstown, MD

10.1097/MS9.0000000000000128
00015
3
Case Reports
Gastrojejunocolic fistula after gastrojejunostomy in eastern Ethiopia: a case report
http://orcid.org/0000-0001-6024-0725
Umer Keno M. MD aDrkenomoh@yahoo.com

http://orcid.org/0000-0002-7385-5224
Nureta Tilahun H. MD bDoittilahun@gmail.com

Akalu Tiruwork F. MD dtirueworkdr@gmail.com

Shale Wongel T. MD tenawongel@gmail.com
c
a Department of General Surgery, College of Medical Sciences, Dire Dawa
b Department of Gastrointestinal Surgery
c Department of General Surgery, College of Medical Sciences, Jimma
d DELT General Hospital, Gastroenterology Unit, Dire Dawa, Somali, Ethiopia
* Corresponding author. Address: Dire Dawa University, Dire Dawa 3020, Ethiopia. Tel.: +251913338816; fax: +251-251-127971. E-mail address: drkenomoh@yahoo.com (K.M. Umer).
3 2023
14 2 2023
85 3 439442
6 9 2022
22 12 2022
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
2023
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Background:

Gastrojejunocolic fistula (GJF) is an infrequent condition that presents late as a complication of gastroenterostomy conducted for complications of peptic ulcer disease and is believed to be a result of continuous acid secretion due to insufficient stomach resection and incomplete vagotomy. Symptoms of the fistula present late, usually 20 years or more after gastroenterostomy. Patients with GJF usually present with chronic on-and-off diarrhea, weight loss, fecal-smelling belching or vomiting, and malnutrition.

Case Presentation:

The case is of a 45-year-old man with GJF who presented with diarrhea, weight loss, and foul-smelling vomiting. The diagnosis was made intraoperatively despite preoperative investigations with computerized tomography scan and endoscopy. The patient underwent a single-stage operation, and the postoperative course was uneventful.

Conclusion:

Knowledge of this uncommon illness can aid in prevention through improved operative strategy and medical treatment during the stomal ulcer phase with proton pump inhibitor and Helicobacter pylori eradication

Keywords

gastroenterostomy
gastrojejunocolic fistula
stomal ulcer
OPEN-ACCESSTRUE
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pmcHighlights

The case is of a 45-year-old man with gastrojejunocolic fistula who presented with chronic diarrhea, weight loss, and foul-smelling vomiting.

Bypass surgery was done 17 years back for the patient.

The patient underwent a single-stage operation, and the postoperative course was uneventful.

Knowledge of this uncommon illness can aid in prevention and have a high index of suspicion of such patients.

Surgical correction is required for such patients, but a nutritional management plan is as important as surgical correction.

Introduction

Gastrectomy and gastrojejunostomy are used to treat recurrent peptic ulcer disease (PUD) and other gastric diseases. Gastrojejunocolic fistula (GJF) is a rare and late consequence of both procedures. GJF is thought to be triggered by the development of a stomal ulcer which can be caused by insufficient stomach resection, incomplete vagotomy, or a lengthy afferent loop. The most common symptoms of GJF are fecal vomiting/breath, recurrent diarrhea, and weight loss1–3.

It is one of the complications that might occur following a gastroenterostomy, such as stenosis, hemorrhage, or perforation. Knowledge of this uncommon illness can aid in prevention through improved operative strategy and medical treatment during the stomal ulcer phase with proton pump inhibitor (PPI) and Helicobacter pylori eradication2.

The preferred diagnostic test is barium enema, with a sensitivity of 95% for this illness. Endoscopy of the upper gastrointestinal tract may also be used to diagnose GJF4 because GJF patients have poor nutritional conditions, operative mortality after surgical repair can be as high as 40%. To reduce mortality, stepwise GJF repair with a preliminary diversion colostomy was previously recommended. However, with the help of extensive preoperative and postoperative support, the one-stage repair is now possible5. Today’s improved surgical technique and equipment have reduced the incidence of GJF to about one out of every seven people with marginal or recurrent ulceration6.

Case report

A 45-year-old male patient presented to DELT Hospital, Dire Dawa, Ethiopia, in January 2022 with a 2-month history of foul-smelling intermittent vomiting. He also has had intermittent chronic diarrhea for the past 2 years, significant weight loss of around 12 kg, and epigastric pain. He has a history of upper abdominal surgery at Hiwot Fana Hospital, Harar, Ethiopia, 17 years back for recurrent vomiting; the document was lost. The patient has no history of smoking or drug use.

At physical examination, the patient was cachectic and dehydrated, his blood pressure was 90/60 mmHg, pulse rate 90 beats per minute, weight 39 kg, abdominal examination showed upper midline vertical surgical scar, and also had grade 1 pitting pedal edema.

The laboratory data on admission, complete blood count revealed a hemoglobin level of 11.7 g/dl (normal range 10.0–16.0) and an albumin level of 3.2 g/dl (normal range 3.8–5.1), serum electrolyte and renal function test was in the normal range. Upper gastrointestinal tract endoscopy shows a deformed duodenal bulb and severe stenosis; difficult to see any stoma because of the presence of gastrointestinal content despite 24 h nil per os (nothing by mouth). A barium study was not done because it was not available. Abdominal computerized tomography with contrast was not helpful preoperatively, but postoperative careful and detailed evaluation showed a GJF (Fig. 1). The patient was taken into the operation theater and an exploratory laparotomy was undertaken. At surgery, a jejunocolic fistula and retrocolic gastroenterostomy were identified (Figs 2, 3). The GJF was undone, the gastric stoma and colonic fistula was circumferentially excised, and around 10 cm of the jejunum was resected. Bowel continuity was restored by jejunojejunostomy, a new gastroenterostomy 15 cm from jejunojejunostomy, and the colonic fistula was refreshed and repaired (Fig. 4). Patient stayed in ICU for 48 h and transferred to the ward, sips started 6th postoperative day, and full diet started by day 10 and discharged at 12th postoperative day with an advice on regular follow-up and lifelong PPI. Recovery was uneventful, and at 2nd month follow-up, he gained 5 kg and recovered well. During his visit, the patient said he was feeling well and resumed his job as a taxi driver.

Figure 1 Computerized tomography scan pictures of the gastrojejunocolic fistula.

Figure 2 Intraoperative picture showing the jejunocolic fistula.

Figure 3 Intraoperative picture of the fistulas.

Figure 4 Pictorial illustration of the procedure.

Discussion

A perforating gastrojejunal ulcer causes a GJF, which commonly occurs as a late consequence of surgical treatment for PUD. A GJF almost always causes serious and progressive nutritional deficiency, which can lead to full debilitation if not surgically rectified7.

The increased use of posterior gastroenterostomy for gastric and duodenal lesions has resulted in an increase in the number of jejunal ulcers, which are the most common cause of GJFs3,8.

The first description and successful treatment of GJF were made by Czerny in 19038.

According to a literature by Priestley and Gibson in 1948, the incidence of jejunal ulcer after gastroenterostomy is around 15%7.

The incidence of GJF among patients with gastrojejunal ulcers has been described with varying results by different literatures. Walters and Clagett reported 13.8%, Lowdonlo about 22.4%, and Judd and Hoerner reported an incidence of 8.7%7.

Up to January 1924, the Mayo Clinic performed 6214 gastroenterostomies for gastric and duodenal ulcers; 88 of these patients (1.41%) acquired a jejunal or gastrojejunal ulcer after surgery, and 10 out of 88 (11.36%) developed a jejunocolic fistula8.

Diarrhea, weight loss, and belch of fecal-smelling gas are the three signs of GJF, according to Marshall. Diarrhea is the most common and critical symptom, as it has a significant impact on the patient’s overall health. It is produced by fecal irritation of the stomach and intestines, not by the shunting of food from the stomach into the colon.

Evidence are: barium enema shows the fistula (95%), then barium meal (30%); temporary colostomy improves the patient’s condition and stops diarrhea, despite the presence of a fistulous contact between the colon and the stomach9.

Another important symptom is a foul-smelling, gaseous belching. It has an unpleasant stench that is sometimes only perceived by others, and it is occasionally followed by fecal regurgitation. Patients are frequently undernourished, dehydrated, and feeble as a result of their weight loss8.

Fecal-smelling belching, feculent vomiting with no obstruction, on-and-off diarrhea containing some undigested food particles, and finally, a syndrome of colonic obstruction in a patient who has previously undergone a gastric operation can lead to the diagnosis of GJF8.

The fistula develops over time, and unless surgical intervention is performed, the outcome is usually catastrophic. Loewy documented 76 cases in which 11 individuals died despite not having surgery8.

A barium enema validated the diagnosis in more than 90% of instances, according to several investigators. A barium meal, on the other hand, only shows fistula 30% of the time. Endoscopy has been suggested in recent reports. Despite the fact that surgery is the only cure for this disease, malnutrition should be treated before surgery, mostly by parenteral nutrition. The goal of surgery for this condition is to completely eliminate the fistula and prevent the stomal ulcer from returning10.

Operation is recommended if a definitive diagnosis of a fistula is obtained. It is occasionally necessary to have nutritional treatment before surgery. According to Loewy’s figures, there were 61.9% cures, 11.1% recurrences, and 27% deaths in 63 procedures of various kinds8.

Procedures for operations should be as straightforward as possible. In cases where the pylorus is not obstructed, a simple closure of the fistula has yielded the greatest outcomes; if there is obstruction, a new gastroenterostomy can be established. A ‘bloc’ resection of the GJF and repair may be necessary if the adhesions are too extensive to allow any operation. If there has been a significant colonic stricture, in some circumstances, resection of the colon and anastomosis is mandatory8.

Because of the significant fatality rate linked with the one-stage procedure in early studies, Lahey in 1938, Pfeiffer and Kent in 1939, and Marshal in 1945 devised multistage procedures. In the recent two decades, the one-stage operation for GJF has become increasingly frequently utilized, thanks to improvements in all aspects of surgical care and the progressive, more extensive use of the one-stage operation for practically all situations7.

The need for surgery to treat PUD has dropped considerably in recent years. Medical advancements, such as the use of H2 receptor blockers, PPIs, and H. pylori eradication regimens, are particularly important.

As a result of the reduction in surgery, the rate of these fistulas has decreased dramatically. Fistula formation usually requires more than 20 years of latent period after the initial surgery; thus, this serious and uncommon consequence could happen right now. As a result, GJF remains a significant and present complication1,5.

Conclusion

GJF is an uncommon but known late complication of gastrojejunostomy done for PUD. A diagnosis of GJF should be considered in a patient with a previous history of gastric surgery, who presents with symptoms of fecal vomiting, chronic diarrhea, and weight loss. Barium enema is sensitive for the diagnosis but upper gastrointestinal endoscopy can also be used for the diagnosis. Even though the condition is cured surgically, preoperative nutritional management and postoperative care are important for the favorable outcome of the patient. One-stage operation is the current surgical management option due to the improved perioperative management of these patients.

Method

The work has been reported in line with the SCARE (Surgical CAse REport) 2020 criteria11.

Ethical approval

Ethical approval was granted by Dire Dawa University’s institutional review board (IRB).

Patient consent

Written informed consent was obtained from the patient to publish this case report per the journal’s patient consent policy.

Sources of funding

This research did not receive any financial support.

Author contribution

K.M.U. is the corresponding author, the operating surgeon, involved in managing the patient, has designed the literature review, acquisition of data and analysis, drafted the manuscript, revised the manuscript, and approved the version of the manuscript to be published. T.H.N. was involved in managing the patient, have designed the literature review, acquisition of data and analysis, drafted the manuscript, revised the manuscript, and approved the version of the manuscript to be published. T.F.A. was involved in the diagnosis of the patient, acquisition of data and analysis, drafted the manuscript, revised the manuscript, and approved the version of the manuscript to be published. W.T.S. was involved in the acquisition of data and analysis, drafted the manuscript, revised the manuscript, and approved the version of the manuscript to be published.

Conflicts of interest disclosure

All authors have no conflicts of interest.

Research registration unique identifying number (UIN)

None.

Guarantor

Keno Mohammed Umer, E-mail: drkenomoh@yahoo.com

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability

The data that support the findings of this case are available from the corresponding author.

Acknowledgments

We would like to thank the patient for his full corporation and all team members for their hard work and constructive comments.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 14 February 2023
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