A case of gastrojejunocolic fistula with steatohepatitis.

A man in his 30s, who had undergone retrocolic Billroth II reconstruction for perforated duodenal ulcer, presented with watery diarrhea for 2 years and suspected fatty liver. He was referred to our hospital for management of chronic diarrhea, weight loss, hepatopathy and hypoalbuminemia. Initial upper and lower gastrointestinal endoscopies were negative. Since a small bowel lesion was suspected, peroral single-balloon enteroscopy was performed, which identified feces-like residue near the Billroth II anastomotic site and a connection to the colon separate from the afferent and efferent loops. Transanal single-balloon enteroscopy identified a fistula between the gastrojejunal anastomosis and transverse colon, with the scope reaching the stomach transanally. Barium enema confirmed flow of contrast medium from the transverse colon through the fistula to the anastomotic site, allowing the diagnosis of gastrojejunocolic fistula. Liver biopsy showed relatively severe steatohepatitis (Brunt's classification: stage 2-3, grade 3). Resection of the anastomotic site and partial transverse colectomy were performed to remove the fistula, followed by Roux-en-Y reconstruction. Postoperatively, watery diarrhea resolved and the stools became normal. Hepatopathy and hypoproteinemia improved. One year later, liver biopsy showed marked improvement of steatosis. This case demonstrated marked improvement of both diarrhea/nutritional status and steatohepatitis after treatment of gastrojejunocolic fistula, suggesting that the fistula caused non-alcoholic steatohepatitis.

Segmental sigmoid polyposis as a colonoscopic indicator of an ileosigmoid fistula in Crohn's ileitis.

BACKGROUND AND AIMS: Ileosigmoid fistulas (ISFs) are frequently undiagnosed prior to surgery. This study was designed to describe a polyp or cluster of polyps limited to the sigmoid colon as a marker of ISF in patients with ileitis. This novel finding will increase a gastroenterologist's opportunity to detect them preoperatively and their prognostic implication of worsening ileitis. METHODS: The medical records of patients with Crohn's disease and ISF were reviewed to determine whether colonoscopy had revealed polyposis limited to the sigmoid colon and its frequency. RESULTS: Thirty-seven patients with Crohn's ileitis complicated by ISF were identified from our database. Twenty had one or more sigmoid polyps without polyps elsewhere in the colon suggesting the site of fistula exit. Fifteen of the patients had ISF and five had ileorectal fistula (IRF). The fistula was detected by various means, including colonoscopy, sigmoidoscopy, small bowel X-ray series, barium enema, computed tomography, and magnetic resonance enterography. The ISF was generally diagnosed prior to the recognition and significance of the segmental polyps. These polyps were inflammatory or hyperplastic on pathologic review. CONCLUSION: Most ISFs and IRFs are now found preoperatively by imaging and some are incidental surgical findings. The segmental sigmoid polyps that we describe should help the gastroenterologist to be suspicious of ISF. The polyps are a surrogate marker for the progression of the fistula and the underlying ileitis as they tend to appear after the fistula has matured and lead to increased intensity of medical therapy well before surgical intervention is required.

Fístula colecistocólica: una causa poco frecuente de hemorragia digestiva baja / Cholecistocolic fistula: an uncommon cause of lower gastrointestinal bleeding

La fístula colecistocólica es un tipo poco común de fístula bilioentérica que tiene una presentación clínica variable y que generalmente aparece como complicación de la enfermedad litiásica biliar. Puede manifestarse en forma de dolor abdominal, náuseas, pérdida de peso, diarrea con o sin esteatorrea asociada, clínica dispéptica y más raramente como hemorragia digestiva baja, colangitis de repetición o incluso como un ileobiliar. Las técnicas más útiles para el diagnóstico son el TC abdominal, los estudios baritados y la colangiopancreatografía retrógrada endoscópica (CPRE).Describimos el caso de una mujer de edad avanzada, pluripatológica, con fístula colecistocólica, que se presentó en forma de hemorragia digestiva baja. Fue estudiada mediante colonoscopia, TC abdominal y enema de bario. Durante el ingreso requirió transfusión de 4 concentrados de hematíes, desestimándose el tratamiento invasivo debido a su comorbilidad de base. Evolucionó favorablemente, con resolución espontanea del cuadro. Dos meses después permanecía asintomática(AU)

Cholecystocolic fistula is an uncommon biliary enteric fistula with a variable clinical presentation that usually appears as a rare complication of gallstone disease. It can present with abdominal pain, nausea, weight loss, diarrhoea with or without associated steatorrhea, and dyspeptic symptoms. Rare cases have been reported with lower gastrointestinal haemorrhage and even with a gallstone ileous. The most useful techniques for diagnosis are CT, barium studies, and ERCP. We report a case of a cholecistocolic fistula in an eldery woman with multiple medical comorbidities that presented as lower gastrointestinal bleeding. She was explored with colonoscopy, abdominal CT and barium enema. She required a total of 4 units of whole blood and because of her comorbidities a decision was made not to proceed with invasive treatment. She had a good evolution and was asymptomatic two months later(AU)

[Hyperbaric oxygen in the treatment of perineal Crohn's disease era of infliximab: a renewal interest?]. / L'oxygénothérapie hyperbare dans le traitement de la maladie de Crohn perineale a l'ère de l'Infliximab : un regain d'intérêt ?

BACKGROUND: Despite the growing number of therapeutic methods and the recent introduction of new drugs more active in the therapeutic arsenal, lesions of the ano-perineal Crohn's disease remains difficult to support. Hyperbaric oxygen (HBO) was made before the era of infliximab, an interesting therapeutic approach in which the current position remains unclear. AIM: To assess HBO efficacy in the treatment of anal fistulas refractory Crohn's disease. METHODS: Literature review. RESULTS: Hyperbaric oxygen therapy was used in the 90's when the biotherapy was not part of the armamentarium for Crohn's disease. Research conducted has identified only nine publications evaluating the efficacy of hyperbaric oxygen therapy in the treatment of anal fistulas refractory Crohn's disease. Among the nine publications, we have retained only four: two clinical trials and two clinical cases. The total number of patients was 22: 12 women and 10 men. The average age of patients was 37 years. The average number of session was 42 sessions. Remission was observed in 15 patients (68.18%) whereas with Infliximab rate is 66%. Adverse events were observed in 2 patients (16.6%). Indeed, instead of considering them as two different alternatives, it should be combined to obtain a synergy to increase response rates, shorten the healing and especially to decrease the recurrence rate. CONCLUSION: Only a prospective randomized controlled trial (with two arms: biotherapy versus biotherapy associated with hyperbaric oxygen therapy) could accommodate this technique in the armamentarium of perineal lesions of Crohn's disease.

[Cholecistocolic fistula: an uncommon cause of lower gastrointestinal bleeding]. / Fístula colecistocólica: una causa poco frecuente de hemorragia digestiva baja.

Cholecystocolic fistula is an uncommon biliary-enteric fistula with a variable clinical presentation that usually appears as a rare complication of gallstone disease. It can present with abdominal pain, nausea, weight loss, diarrhoea with or without associated steatorrhea, and dyspeptic symptoms. Rare cases have been reported with lower gastrointestinal haemorrhage and even with a gallstone ileous. The most useful techniques for diagnosis are CT, barium studies, and ERCP. We report a case of a cholecistocolic fistula in an elderly woman with multiple medical comorbidities that presented as lower gastrointestinal bleeding. She was explored with colonoscopy, abdominal CT and barium enema. She required a total of 4 units of whole blood and because of her comorbidities a decision was made not to proceed with invasive treatment. She had a good evolution and was asymptomatic two months later.

Pneumobilia, chronic diarrhea, vitamin K malabsorption: a pathognomonic triad for cholecystocolonic fistulas.

Cholecystocolonic fistula (CF) is an uncommon type of internal biliary-enteric fistulas, which comprise rare complications of cholelithiasis and acute cholecystitis, with a prevalence of about 2% of all biliary tree diseases. We report a case of a spontaneous CF in a 75-year-old diabetic male admitted to hospital for the investigation of chronic watery diarrhea and weight loss. Massive pneumobilia demonstrated on abdominal ultrasound and computerized tomography, along with chronic, bile acid-induced diarrhea and a prolonged prothrombin time due to vitamin K malabsorption, led to the clinical suspicion of the fistula. Despite further investigation with barium enema and magnetic resonance cholangio-pancreatography, diagnosis of the fistulous tract between the gallbladder and the hepatic flexure of the colon could not be established preoperatively. Open cholecystectomy with fistula resection and exploration of the common bile duct was the preferred treatment of choice, resulting in an excellent postoperative clinical course. The incidence of biliary-enteric fistulas is expected to increase due to the parallel increase of iatrogenic interventions to the biliary tree with the use of endoscopic retrograde cholangio-pancreatography and the increased rate of cholecystectomies performed. Taking into account that advanced imaging techniques fail to demonstrate the fistulas tract in half of the cases, and that CFs usually present with non-specific symptoms, our report could assist physicians to keep a high index of clinical suspicion for an early and valid diagnosis of a CF.

[A very extensive necrotizing fasciitis]. / Une fasciite nécrosante très extensive.

Necrotizing fasciitis is a severe skin infection. Fluidized bed may be indicated to improve healing. We report a 36-year-old woman case, who developed an important skin emphysema on a fluidized bed that may have worsen the situation.

[Surgical complications of the diverticular disease. A rare case of sigmoid-vaginal fistula]. / Le complicanze chirurgiche della malattia diverticolare: un raro caso di fistola sigmoido-vaginale.

The Authors report on a rare case of diverticular disease complicated by a sigmoid- vaginal fistula with personal considerations based on a review of literature. A 75 year old patient becomes to our observation suffering the lost of smelly vaginal secretions without fever or abdominalgia. In anamnesis hysterectomy cholecystectomy appendectomy and visceral adhesions lysis. Colonoscopy RX barium enema, gynaecological examination, vaginal buffer show diverticulis of colon sigma with sigmoid-vaginal fistula. After laparotomy, visceral adhesions lysis, it was done sigmoid- vaginal fistula resection with healing. Diverticular disease is a XX century pathology with incidence (for some authors) of 50% of population. Symptomatic forms affect 30-50% of patients (variable percentage based on age); the 1% of these need surgery. The colonic anatomical-functional disorder is the principal cause of diverticular disease that recognize the main localization in colon-sigma. Diverticulitis with pericolic inflammation are frequent complications; possible evolutions are local tamponed peritonitis, mechanical intestinal occlusion, hemorrhage from colonic wall and fistulas. Sigmoid-vaginal fistula is the most frequent in women previously treated with laparohysterectomy. The colonoscopy and RX barium enema are gold standard for instrumental diagnosis; the vaginography is diriment, urography excludes urological diseases. The surgical treatment is the fistula resection, with or without colonic resection. In consideration of the necessity of conservative surgery and on the basis of this case, the authors suggest, if it's possible, the simple fistula resection, although the literature report an high number of relapses.

Uretero-appendiceal fistula.

We report a case of uretero-appendiceal fistula. A 63-year-old woman was admitted to our hospital with high grade fever and loss of 5 kg of body weight over 6 months. Pyonephrosis was diagnosed. A retrograde ureterogram and barium enema showed a connection between cecum and ureter. Right nephroureterectomy and right hemicolectomy were carried out. The final diagnosis was uretero-appendiceal fistula.

[Carcinoma arising from ileorectal fistula in a patient with Crohn's disease].

A 72-year-old man was given a diagnosis of Crohn's disease in 1976 at age 44, and partial resection of is ileum was performed. In November 1982, barium enema examination revealed on ileorectal fistula. As he had no complaint, conservative therapy was chosen. In August 2003, he had high fever and CT scan revealed presacral abscess. Ileocecal resection, partial resection of is small intestine and loop sigmoid colostomy were performed. In December 2004, the serum level of CEA was gradually elevated and he complained of anal mucus discharge. Endoscopic examination showed a fistula orifice in the rectum and biopsy of the fistula revealed mucinous adenocarcinoma. We performed abdominoperineal resection of the rectum with partial resection of the sacrum. We thought that careful observation helped the detection of such a rare case of carcinoma arising from a fistula tract.

Review article: Medical therapy for fistulizing Crohn's disease.

BACKGROUND: Fistulae will develop in approximately one-third of patients with Crohn's disease. With an expected spontaneous healing rate of only 10%, fistulizing Crohn's disease requires a comprehensive strategy with a medical and possible surgical approach. AIM: To summarize the current literature evaluating various medical options for treating patients with fistulizing Crohn's disease. METHODS: A literature review was conducted using PubMed (search terms: Crohn's disease and fistula) and manual search of references among the identified studies and relevant review papers to identify papers that present data on medical treatment of fistulizing Crohn's disease. RESULTS: The first line of medical therapy remains antibiotics (metronidazole and ciprofloxacin). Mercaptopurine and azathioprine are medications that are effective in treating fistulizing Crohn's disease. The current gold standard of medical treatment to induce and maintain remission for fistulizing Crohn's disease is infliximab. Used as induction therapy, infliximab produced a 62% clinical response, and a complete closure rate of 46%. A maintenance therapy trial demonstrated at 54 weeks, 46% of patients receiving infliximab continued to respond to treatment, compared with 23% in the placebo group (P = 0.001). CONCLUSION: Further research to find new therapies and to improve our existing medical treatment of fistulizing Crohn's disease is required.

Cholecystocolonic fistula preoperatively diagnosed by endoscopic ultrasound of the colon.

The patient was a 58-year-old woman. Gallbladder stones and occult blood in feces were detected during a physical check-up, then the patient was referred to Nagoya University Hospital. In this case the fistula was difficult to diagnosed by ultrasound and endoscopic ultrasound (EUS) of the upper intestinal tract because the gallbladder was filled with stones. Barium enema and endoscopic retrograde cholangiopancreatography did not reveal fistula. Curved-linear array EUS of the colon showed fistula.

Aortoduodenal fistula complicated by acupuncture.

Recently, acupuncture has become a common therapeutic procedure for pain control worldwide. Although it has been repeatedly reported that acupuncture is effective and safe, several serious complications were also reported. In this article, we present a case of 68-year-old man who died of massive hematemesis resulting from aortoduodenal fistula (ADF), a rare complication of acupuncture therapy.

Refeeding syndrome in patients with gastrointestinal fistula.

OBJECTIVE: Although refeeding syndrome has been well documented in starved patients, obese patients, those with anorexia nervosa, malnourished elderly individuals, and certain postoperative patients, little is known about the presence and the importance of refeeding syndrome in patients with gastrointestinal fistula and insufficient nutrition support over the long term. The objective of this study was to estimate the morbidity of this syndrome in these patients, to assess the safety and efficacy of our graduated refeeding regimen, and to emphasize the importance of this syndrome. METHODS: One hundred fifty-eight patients with gastrointestinal fistula during the past 2 y were reviewed. RESULTS: Fifteen of these patients were diagnosed as having refeeding syndrome. They were started on the refeeding procedure according to our regimen, and changes in their serum levels of electrolytes were recorded. The symptoms and signs they presented were noted. All patients were successfully advanced to full nutrition support. During the refeeding procedure, patients presented with weakness, paralysis of limbs, slight dyspnea, paresthesia, tachycardia, edema, and diarrhea. Serum phosphorus concentration decreased in all patients within 24 h of refeeding, reaching a mean nadir after 3.3 +/- 1.5 d and another 6.1 +/- 2.1 d to return to above 0.70 mM/L upon phosphorus supplementation. Three patients treated with growth hormone presented more severe hypophosphatemia (<0.20 mM/L) than the others. CONCLUSIONS: 1) Refeeding syndrome occurs commonly in patients with malnutrition secondary to gastrointestinal fistula. 2) Alterations in phosphate metabolism are central to the refeeding syndrome. 3) Supplementation with electrolytes (including especially phosphate) and vitamins is the focal point of the treatment of this syndrome. 4) Growth hormone treatment may aggravate hypophosphatemia.

[Gastrocolic fistula - a rare cause of cachexia and polyneuropathy]. / Gastrokolische Fistel als seltene Ursache von Kachexie und Polyneuropathie.

Gastrocolic fistula is a rare clinical disorder which in the past most often occurred after gastric surgery or carcinoma of the gastrointestinal tract. However, during the last decade an increasing number of cases after benign gastric ulcers have been described. Most common symptoms have been weight loss, abdominal pain, diarrhea and copremesis. A 49-year-old cachectic patient presented with a 2-year history of abdominal discomfort and diarrhea. He reported a weight loss of 32 kg during this period and was finally unable to move because of exhaustion. Furthermore, he suffered of burning paresthesia of the legs and the abdomen. His medical history included a Billroth II operation because of recurrent ulcer disease in 1987. Barium enema revealed a gastrocolic fistula which caused small bowel bacterial overgrowth with villous atrophy and malabsorption and development of polyneuropathy. The fistula was surgically resected, and postoperatively, the patient improved and regained his weight. Gastrocolic fistula is a rare cause of diarrhea and should be considered in clinical practice. Barium enema is superior to endoscopy in detecting gastrocolic fistula.