Gastroscope Meeting the Colonoscope: A Rare Complication After Billroth II Gastrojejunostomy

CASE REPORT

We report a rare case of a 42-year-old man who presented with a gastrocolic fistula after Billroth II gastrojejunostomy for gastric epithelial adenoma. The patient endorsed typical symptoms of Gastrocolic Fistula (GCF), including chronic diarrhea, foul-smelling belching, feculent vomiting, and an unintentional weight loss of 20 pounds.^1,2 On examination, he was found to have scrotal and lower extremity edema. Laboratory test results showed an albumin of 1.6 g/dL (3.5–5.2), potassium of 3.0 mmol/L (3.4–5.2), and hemoglobin of 7.9 mg/dL (11.0–14.7).

Imaging showed postsurgical changes of the stomach, diffuse anasarca, and a fistulous connection between the mid-body of the stomach and the mid-transverse colon (Figure 1). Subsequent endoscopy revealed a patent Billroth II gastrojejunostomy and a large opening adjacent to the anastomosis leading to the colon (Figure 2). The transverse colon was tattooed preceding colonoscopy (Figure 3). The colonoscope easily passed from the transverse colon to the stomach, which confirmed the presence of a GCF (Figure 4). Ultimately, the patient underwent surgical correction, leading to resolution of his symptoms.

Figure 1: CT Scan abdomen and pelvis exhibiting a fistula between the mid-body of the stomach and the mid-transverse colon.

Figure 2.: Endoscopy revealing the gastrojejunostomy (upward-pointing arrow) and gastric-colonic fistula (downward-pointing arrow).

Figure 3: Gastric-Colonic fistula on upper endoscopy, tattooed.

Figure 4: Tattooed area was noted in the transverse colon during colonoscopy.

We propose that the GCF formed because of an anastomotic leak from a remote Billroth II, which contributed to a prolonged inflammatory process and epithelial cell migration into deep layers, ultimately resulting in a communication between adjacent organs.

DISCLOSURES

Author contributions: A. Abulawi: Writing—original draft, reviewed the literature, revised the manuscript for intellectual content, and approved the final manuscript; J. Liu: Writing—original draft, reviewed the literature, revised the manuscript for intellectual content, and approved the final manuscript; R. Bui: Writing—reviewing and editing, revised the manuscript for intellectual content, and approved the final manuscript; and A. Batool: Writing—review and editing, revised the manuscript for intellectual content, and approved the final manuscript, and is the article guarantor.

Acknowledgments: The authors express gratitude to the patient.

Financial disclosure: None to report.

Previous presentation: This case was presented at the American College or Gastroenterology 2021 Annual Scientific Meeting; October 26, 2021; Las Vegas, Nevada.

Informed consent was obtained for this case report.