Case Reports

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Patient 1

A 52-year-old woman with steroid-dependent chronic obstructive pulmonary disease had sudden onset of nausea, vomiting, and diarrhea. She had no weight loss or gastrointestinal bleeding. Before the acute event the patient had had intermittent mild abdominal discomfort of several months duration for which she took an over-the-counter medication [containing aspirin] and antacids. Other medications included prednisone, 20 mg per day, for several years. An upper gastrointestinal barium study showed a gastrocolic fistula Figure 1, top left). She was started on cimetidine, 400 mg three times a day, and the prednisone was reduced to 10 mg per day. Surgery was planned but was delayed because of the patient's poor respiratory status. In the meantime, her symptoms improved markedly. Six weeks later, gastroscopy showed a proximal antral ulcer from which multiple biopsies were obtained, showing acute and chronic inflammation without evidence of malignancy. On repeated radiographic studies, no fistula was found Figure 1, top right and bottom left). Four and one half years later the patient is doing well.

View larger version (114K): [in this window] [in a new window]   Figure 1. A 52-year-old woman (Patient 1) with nausea, vomiting, and diarrhea. Top left. An upper gastrointestinal barium study shows a large greater curvature ulceration (straight arrows). Barium from the stomach has filled the distal transverse colon (TC) through the penetrating ulcer (curved arrow). Top right. An upper gastrointestinal barium study shows a large greater curvature ulceration (straight arrows). Barium from the stomach has filled the distal transverse colon (TC) through the penetrating ulcer (curved arrow). Top right. An upper gastrointestinal barium study 6 weeks later shows deformity of the greater curvature (solid arrow) at the site of the previous ulcer; no fistula is shown. Bottom left. A barium enema performed at the same time shows a similar persistent deformity (empty arrow) along the superior haustral row of the distal transverse colon.

Patient 2

A 65-year-old woman with degenerative joint disease had diarrhea, appearance of poorly digested food in the stool, and a 14-kg weight loss in the past 3 months. She had no abdominal pain, nausea, vomiting, or history of peptic ulcer disease or abdominal surgery. Medications included naproxen, 375 mg three times a day, which she had taken for several years. The physical examination showed a nontender abdominal mass in the epigastrium. A rectal examination was normal without occult blood in the stool. Laboratory data included normocytic, normochromic anemia. A barium enema identified narrowing in the transverse colon with a fistulous tract to the stomach that filled with contrast. Upper endoscopy showed a deep, benign-appearing gastric ulcer on the greater curvature. Acute and chronic inflammation was found on biopsy without evidence for malignancy. A CLOtest (Tri-Med Specialties, Lenexa, Kansas) for Helicobacter pylori was negative. Colonoscopy did not reveal any lesion. An abdominal computed tomography scan showed mesenteric thickening in the area of the gastrocolic fistula. Because of the chronic presentation, it was decided to treat the patient medically with ranitidine, 300 mg twice daily for 12 weeks; and carafate, 1 g four times a day for 3 weeks; and to discontinue use of naproxen. An upper endoscopy done after 3 months of therapy showed a well-healed scar in the area of the previous ulcer. The patient became asymptomatic within 1 week of initiation of therapy and continues to do well 18 months later.

Discussion

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Gastric and colonic malignancies are the most commonly reported causes of gastrocolic fistula in patients without previous gastric surgery. A benign gastric ulcer is rarely complicated by gastrocolic fistula. Madsen and colleagues [4] have reviewed the literature from 1920 to 1978, and an update was published by Soybel and associates in 1989 [3]. Most patients with benign gastrocolic fistula are middle-aged women, and 50% to 75% of the most recently reported patients used anti-inflammatory drugs (nonsteroidal anti-inflammatory drugs, aspirin, and, to a lesser extent, steroids). Casey and Lorenzo [5] noted that 23% of reported patients during the 1960s were using aspirin or steroids compared to 43% during the 1970s, suggesting that this association is becoming more common or recognized.

Symptoms are varied and often nonspecific, with two thirds of the patients experiencing epigastric pain, diarrhea, and weight loss. Occult or obvious gastrointestinal bleeding occurs in 25% to 33%. Vomiting can be feculent. An abdominal mass is rarely described [1]. Diagnosis of the fistula is most often made by barium enema, less often by upper gastrointestinal x-ray series, and rarely by gastroscopy or colonoscopy. It is important, however, to exclude a malignancy by obtaining multiple biopsy samples from the gastric ulcer during endoscopy. Benign gastrocolic fistula has traditionally been treated surgically, but five cases have been reported in which medical therapy was successful [6-9]. In three of these cases nonsteroidal anti-inflammatory drugs and steroids were implicated [7, 8]. The time to healing ranged from 2 to 16 weeks; the average was 9 weeks.

Benign gastrocolic fistula might be underdiagnosed, especially in patients with relatively mild symptoms that could be related to the use of anti-inflammatory medication. The fistula can be difficult to demonstrate on diagnostic studies and might heal rapidly with medical treatment alone. If, in addition to discontinuing ulcerogenic drugs, medical therapy does not lead to improvement or if signs of free perforation or uncontrollable bleeding occur, then the patient must be considered for surgical intervention. Our two patients show that some patients with benign gastrocolic fistula and relatively mild symptoms respond to medical management.