Nisan 2013

28-29

Meltem ERGÜN¹ , Fatih Oğuz ÖNDER ² , Nurgül ŞAŞMAZ ²

Department of Gastroenterology, ¹ Şişli Etfal Educating and Training Hospital, İstanbul
Department of Gastroenterology, ² Türkiye Yüksek İhtisas Education and Training Hospital, Ankara

Gastrojejunokolik fistül gastroenterostominin nadir ve geç komplikasyonudur. Hastalık operasyondan 20 yıl sonra bile ortaya çıkabilir. Gastrojejunokolik fistül tanısı hastalığın nonspesifik semptomatolojisi nedeniyle güçtür. En sık tanı araçları baryumlu grafi ve endoskopidir. Biz gastrojejunokolik fistülü olan ve tanısını eş zamanlı kolonoskopi ve endoskopi ile koyduğumuz bir vakayı sunuyoruz.

Gastrojejunokolik fistül, gastroenterostomi, kolonoskopi

Gastrojejunocolic fistula (GJF) is an unusual, late complication of gastroenterostomy. GJF is generally considered to be induced by a stomal ulcer due to inadequate gastric resection, incompleteness of vagotomy and long afferent loop (1,2). The most frequent symptoms are upper abdominal pain, severe weight loss, diarrhea, halitosis, and sometimes fecal vomiting (3). The diagnosis is most reliably and frequently made by barium enema and gastroscopy (4,5). The treatment of GJF consists mainly of nutritional support with parenteral or enteral hyper-alimentation and resective surgery (5).

Gastrojejunocolic fistula (GJF) is a late, severe complication of a stomal ulcer, which develops as a result of inadequate resection of the stomach or incomplete vagotomy (1). As a result of the recent development of proton pump inhibitors and Helicobacter pylori eradication regimens for the treatment of peptic ulcers, the necessity of peptic ulcer surgery has decreased, and the occurrence of GJF has decreased remarkably. However, GJF should be recognized as one of the late severe complications observed after a gastrectomy with Billroth II reconstruction, since this disease may occur even 20 years after the first operation for peptic ulcer (2,3). Marginal ulcer occurs in 3% of patients post-Billroth II subtotal gastrectomy; it occurs in less than 1% if truncal vagotomy is included, but in up to 30% of patients with gastroenterostomy without vagotomy (6,7). Marginal ulcer can be complicated by perforation, hemorrhage and GJF. Diarrhea, weight loss, halitosis, and feculent vomiting subsequent to gastroenterostomy should call attention to possible GJF. Short-circuiting the length of the small intestine, bacterial overgrowth and colonic bacteria spilling over the entire proximal gastrointestinal tract were the reasons for the symptoms. Barium enema is the most accurate examination for establishing the diagnosis of GJF (8). Esophagogastroduodenoscopy and colonoscopy are also helpful, not just for the diagnosis but also to rule out any malignant disease. GJF is usually not negotiable with endoscopes because of its complex routings. In some cases, like ours, the simultaneous use of two endoscopes clearly identified the fistula pathway (9). In conclusion, GJF, although rare, should be kept in mind when patients with a history of prior gastrectomy with Billroth II reconstruction suffer from symptoms such as diarrhea or fecal vomiting and weight loss.

Gastrojejunocolic fistula (GJF) is a late, severe complication of a stomal ulcer, which develops as a result of inadequate resection of the stomach or incomplete vagotomy (1). As a result of the recent development of proton pump inhibitors and Helicobacter pylori eradication regimens for the treatment of peptic ulcers, the necessity of peptic ulcer surgery has decreased, and the occurrence of GJF has decreased remarkably. However, GJF should be recognized as one of the late severe complications observed after a gastrectomy with Billroth II reconstruction, since this disease may occur even 20 years after the first operation for peptic ulcer (2,3). Marginal ulcer occurs in 3% of patients post-Billroth II subtotal gastrectomy; it occurs in less than 1% if truncal vagotomy is included, but in up to 30% of patients with gastroenterostomy without vagotomy (6,7). Marginal ulcer can be complicated by perforation, hemorrhage and GJF. Diarrhea, weight loss, halitosis, and feculent vomiting subsequent to gastroenterostomy should call attention to possible GJF. Short-circuiting the length of the small intestine, bacterial overgrowth and colonic bacteria spilling over the entire proximal gastrointestinal tract were the reasons for the symptoms. Barium enema is the most accurate examination for establishing the diagnosis of GJF (8). Esophagogastroduodenoscopy and colonoscopy are also helpful, not just for the diagnosis but also to rule out any malignant disease. GJF is usually not negotiable with endoscopes because of its complex routings. In some cases, like ours, the simultaneous use of two endoscopes clearly identified the fistula pathway (9). In conclusion, GJF, although rare, should be kept in mind when patients with a history of prior gastrectomy with Billroth II reconstruction suffer from symptoms such as diarrhea or fecal vomiting and weight loss.

1. Damata G, Rahili A, Karimdjee-Soilihi B. Gastrojejunocolic fistula after gastric surgery for duodenal ulcer: case report. G Chir 2006;27:360-2. 2. Filipovic B, Randjelovic T, Nikolic G. Gastrojejunocolic fistula as a complication of Billroth II gastrectomy: a case report. Acta Chir Belg 2008;108:592-4. 3. Chung DP, Li RS, Leong HT. Diagnosis and current management of gastrojejunocolic fistula. Hong Kong Med J 2001;7:439-41. 4. Ohta M, Konno H, Tanaka T, et al. Gastrojejunocolic fistula after gastrectomy with Billroth II reconstruction: report of a case. Surg Today 2002;32:367-70. 5. Kece C, Dalgic T, Nadir I, et al. current diagnosis and management of gastrojejunocolic fistula. Case Rep Gastroenterol 2010;4:173-7. 6. Grace PA, Pitt HA, Longmire WP. Pylorus preserving pancreaticoduodenectomy: an overview. Br J Surg 1990;77:968-74. 7. Jordan JH, Hocking MP, Rout WR, Woodward ER. Marginal ulcer following gastric bypass for morbid obesity. Am Surg 1991;57:286-8. 8. Wilson RG, Wilson KS, Champion HR. Gastrojejunocolic fistula. J R Coll Surg Edinb 1973;18:227-30. 9. Nussinson E, Samara M, Abud H. Gastrojejunocolic fistula diagnosed by simultaneous gastroscopy and colonoscopy. Gastrointestinal Endosc 1987;33:398-9