Case Discussion < Presentation of Case > 　　An 84-year-old woman was admitted to the hospital because of vomiting and diarrhea for one week. She had been in her usual state of health until approximately 3 months earlier before this evaluation, when intermittent epigastric pain developed. The pain was dull in character. It was aggravated after food ingestion and could be relieved after taking an antacid. The pain would sometimes wake her up in the midnight. She also had an unintended weight loss of more than 6 kg over the past three months, but she denied passage of tarry or black stools. She frequently took non-steroidal anti-inflammatory drugs for her low back pain in the preceding year. She suffered from vomiting and malaise since one week before this admission. The vomitus, foul in odor, looked like fecal material. Besides, she also had diarrhea soon after a meal in recent one week. She was brought to the hospital because of aggravation of her symptoms and a fever up to 38.6℃ for one day. 　　 On examination, she appeared cachectic and acute ill-looking. The temperature was 38.6℃, the pulse rate was 86 beats per minute, and the blood pressure was 142/84 mmHg. The conjunctiva was pale. The neck was supple without lymphadenopathy. The chest expanded symmetrically and the breath sounds were clear. The bowel sound was normoactive. The abdomen was flat and soft. Mild tenderness was noted at the epigastric region but there was no rebound tenderness. < Laboratory and Image Study > 1. CBC/DC WBC RBC MCV MCHC Hb Hct PLT K/μL M/μL fL g/dL g/dL % K/μL 21.1 2.90 80.6 33.5 8.8 26.3 182 Seg Mono Eos Baso Lym % % % % % 87 3 1 0 9 2. Biochemistry BUN Cr Na K AST ALT Glu CRP mg/dL mg/dL meq/L meq/L U/l U/l mg/dL mg/dL 21 1.4 136 3.4 24 30 96 8.6   3. Urine analysis: Appearance Sp.gr PH Protein Glu Ketone Clear 1.007 6.0 -- -- -- OB Urobilinogen (EU/dL) WBC (/HPF) RBC (/HPF) Cast (/LPF) Crystal (/LPF) -- 0.1 0-1 0-1 -- --   < Course and Treatment > 　　An esophagogastroduodenoscopy (EGD) revealed a large amount of semi-formed feces at the greater curvature of the corpus and fundus of the stomach (Figure A). After irrigation and removal of some fecal materials were performed, a huge ulcer was identified (Figure B, retroflex view). During the examination, air bubbles appeared on a volcano-like area (B, long arrow) at the ulcer crater, indicating a communication of the gastric ulcer with another hollow organ. A computed tomography (CT) of the abdomen showed passage of barium from the stomach into the colon directly through a fistula (short arrow) soon after ingestion of the barium meal (Figure C and D). Pathology of the gastric biopsy from the ulcer margin and ulcer crater revealed no malignant cells. Treatment with a proton-pump inhibitor and antibiotics, and parenteral nutrition were begun. The patient declined the suggestion of surgery. She died of sepsis one month later. < Analysis > 　　Feculent vomiting usually occurs in patients with obstruction of the lower gastrointestinal tract. Formed or semi-formed feces in the stomach should raise the suspicion of coprophagy or gastrocolic fistula. Gastrocolic fistula was first reported by Haller et al. in a patient with abdominal cancer in 1755. Two case series in 1993 showed that about 50-65% gastrocolic fistula cases were secondary to benign gastric ulcers. About 50-75% of the reported patients with benign gastrocolic fistula used anti-inflammatory drugs (aspirin, NSAIDs, and steroids) prior to the occurrence of the fistula. Two-thirds of them were female, with a mean age of 52 years. Other rare causes include after abdominal surgery, inflammatory bowel disease, diverticular disease, tuberculosis, and pancreatic abscess. Symptoms of benign gastrocolic fistula include weight loss (67%), epigastric pain (63%), diarrhea (63%), and fecal vomiting (47%). Diarrheas containing undigested food particles, “red diarrhea” within an hour of eating of red gelatin, and “cold diarrhea” soon after drinking iced tea have been reported. 　　These gastric ulcers are usually located along the greater curvature of the stomach. Barium enema is the best method to detect the gastrocolic fistula (visualized in 90-100% of cases), probably due to the higher intraluminal pressures generated with this procedure. Barium meal and EGD may also detect the fistula in 70-84% and 70-73% of the patients, respectively. CT scan soon after barium meal is helpful in detecting the fistula and excluding gastrocolic fistula secondary to malignancy. Biopsy should be taken from the ulcer to exclude malignancy during endoscopy. Surgical treatment is the treatment of choice for gastrocolic fistula, although conservative treatment with parenteral nutritional support, discontinuing ulcerogenic drugs, and acid-suppressive therapy may be attempted in some patients with benign gastrocolic fistula in the absence of peritoneal sign.   < References > Soybel DI, Kestenberg A, Brunt EM, Becker JM. Gastrocolic fistula as a complication of benign gastric ulcer: report of four cases and update of the literature. Br J Surg 1989;76:1298-1300. Tavenor T, Smith S, Sullivan S. Gastrocolic fistula: a review of 15 cases and an update of the literature. J Clin Gastroenterol 1993;16:189-91. Levine MS, Kelly MR, Laufer I, Rubesin SE, Herlinger H. Gastrocolic fistula: the increasing role of aspirin. Radiology 1993; 187:359-61. 繼續教育考題 1. (C) Which of the following lesion(s) is (are) more likely to be associated with gastrocolic fistula? 1.gastric cancer, greater curvature side; 2.rectal cancer; 3.benign gastric ulcer, lesser curvature side; 4.Crohn’s disease; 5.pancreatic body abscess A (1)+(2)+(4)+(5) B (1)+(3)+(4) C (1)+(4)+(5) D (1)+(3) +(4)+(5) E (1)+(2)+(3) +(4)+(5) 2. (B) Which of the following are typical symptoms of benign gastrocolic fistula? 1. feculent vomiting; 2.diarrhea; 3. weight loss; 4.abdominal distention; 5.constipation. A (1)+(2)+(4) B (1)+(2)+(3) C (1)+(2) +(3)+(4) D (1)+(2)+(3) +(4)+(5) 3. (C) Which of the following drugs are risk factors for benign gastrocolic fistula? 1.aspirin; 2. misoprostol; 3.prednisolone; 4. indomethacin; 5. esomeprazole A (1)+(2)+(3) B (1)+(2)+(3) +(4) C (1)+(3) +(4) D (1)+(2)+(3) +(4)+(5) 4. (B) Which of the following statements is true regarding the etiology of gastrocolic fistula caused by benign gastric ulcer? A Alcoholism is an important risk factor B 50% to 75% of the most recently reported patients used anti-inflammatory drugs C Helicobacter pylori is the most important etiologic factor of benign gastrocolic fistula D All of the above are true 5. (B) Which of the following is the most sensitive test in detecting gastrocolic fistula? A Upper GI series (barium meal) B Lower GI series (barium enema) C Upper endoscopy D Colonoscopy 6. (A) Which of the following is the treatment of choice for malignancy-related gastrocolic fistula？ A Surgical treatment, such as en bloc resection B Chemotherapy C Radiotherapy D B+C 答案解說 ( C ) gastrocolic fistula 因解剖學上位置的關係，一般是發生在胃的大彎與橫結腸 ( B ) gastrocolic fistula 臨床症狀(Triad)主要是 feculent vomiting, diarrhea, and body weight loss ( C ).aspirin, prednisolone以及indomethacin都曾被報告過與gastrocolic fistula之形成有相關; 而misoprostol 可用來預防及治療NSAID 所引起之潰瘍，esomeprazole (proton pump inhibitor) 也是用來治療潰瘍的藥物，兩者與gastrocolic fistula之形成無關 ( B ) 文獻上之報告顯示NSAID 是形成gastrocolic fistula 最重要的病因，至於Helicobacter pylori 與alcohol 目前並未被證實與gastrocolic fistula之形成有明顯相關; ( B ) 由於Barium enema 灌入鋇劑時需加壓，因此最容易將gastrocolic fistula顯影出來 ( A ) 惡性腫瘤所引起之gastrocolic fistula在沒有禁忌症(contraindication)時，手術治療是首要的治療方式