Gastrocolic fistula as a complication of benign gastric ulcer

Background. While most of the complications of benign gastric ulceration are predictable, gastrocolic fistulation is rare and deceptive in presentation. In this review we present 14 such cases and highlight the role of nutritional support in patient management. Patients and methods. Fourteen patients presenting at a surgical ward at King Edward VII Hospital, Durban, with gastrocolic fistula as a complication of benign gastric ulcer between 1983 and 1994 were retrospectively reviewed. Patients were categorised clinically into two groups. Group A patients (N = 8) underwent surgery and group B patients (N = 6) received total parenteral nutrition (TPN) and an H-2 antagonist before surgery. Results. There were 9 male and 5 female patients with a mean age of 42 years. Smoking was noted in 43% of patients and alcohol use in 64%. Only 1 patient used non-steroidal antiinflammatories. Diarrhoea (71%) and weight loss (71%) were the commonest presenting complaints. Gastroduodenoscopy always diagnosed the presence of ulcers (N = 14), but overlooked fistula in 9 patients. Barium meal examination diagnosed fistula in 4 out of 6 patients and barium enema examination did so in 8 out of 9. Colonoscopy was used in 4 patients and diagnosed fistula in 2. One patient who presented with haematemesis had the fistula diagnosed at surgery. All group A patients underwent partial gastrectomy with a Billroth I gastroduodenotomy and segmental colonic resection with primary anastomosis. There was no recurrence during the follow-up period (6 - 104 weeks). Group B patients received TPN for a mean period of 16 days (7 - 32 days). One death resulted from catheter-related sepsis. The remaining 5 fistulas closed with this regimen. Conclusion. An en bloc resection and primary reconstruction is the recommended surgical treatment for gastrocolic fistula. Nutritional deficiencies often exist and nutritional support is beneficial. Most patients will heal on TPN and medical management, but histological exclusion of malignancy must always be obtained. All patients should therefore undergo surgery, even if closure of the fistula is demonstrated, in order to avoid recurrent gastrocolic fistulation and to obtain conclusive evidence of the nature of the underlying pathology.