Gastrointestinal: An Unexpected Scene of Epigastric Pain in Chronic Pancreatitis

A 44-year-old male patient with a history of alcohol-related chronic pancreatitis received pylorus-preserving pancreaticoduodenectomy (PPPD) 2 years ago but is still on alcohol drinking. He presented to the hospital for left epigastric pain and decreased appetite for 2 days. He complained that food intake would be rapidly defecated undigested in a few minutes. His wife also mentioned his hiccups smell like feces. Weight loss, diarrhea, and feculent vomiting were also noted.

Upon the arrival of the hospital, his vital signs showed hypotension (89/59 mmHg). His physical examination revealed a body mass index of 12 kg/m², obvious epigastric tenderness, and rebound tenderness in the middle upper quadrant of the abdomen. The laboratory test results revealed white blood cell count was 6.8 × 109/L (reference range, 3.5–9.5 × 109/L), hemoglobin was 11.7 g/dL (reference range, 13.0–17.5 g/dL), and platelet count was 242 × 109/L (reference range, 125–350 × 109/L). Albumin was decreased (1.7 g/dL; reference range, 40–55 g/dL). Serum creatine, liver function, and lipase were normal.

The abdominal CT demonstrated a pseudocyst along the pancreatic tail and a fistula between gastrojejunostomy and splenic flexure of the colon with a peripancreatic abscess (Figure 1). A percutaneous pigtail drainage tube was inserted into the abscess, and the pus culture yielded Escherichia coli and Candida albicans. Intravenous ceftriaxone and fluconazole were prescribed, but his epigastric pain persisted. The upper endoscopy revealed a huge fistula open with feces in the stomach and a pigtail drainage tip near the anastomosis site (Figure 2a). What's the diagnosis and the treatment?

Answer: Gastrocolic fistula by chronic pancreatitis

Contrast medium injected from the percutaneous pigtail drainage confirmed the gastrocolic fistula (Figure 2b). The subsequent colonoscopy also found the fistula from the splenic flexure (Figure 2c). He was prohibited from oral intake, and total parenteral nutrition (TPN) was given for 1 month. The drainage tube was then removed.

However, liquid food intake was still rapidly defecated undigested in few minutes. A repeated upper endoscopy revealed incomplete healing of the fistula open (Figure 2d). To close the gastrocolic fistula, argon plasma coagulation was applied to the surface of the fistula for de-epithelialization (Figure 2e). One MANTIS clip (Boston Scientific) and two hemoclips were placed for the fistula closure (Figure 2f). After that, the patient's symptoms were relieved.

Gastrocolic fistulas are abnormal connections between the stomach and the colon. Gastrocolic fistulas are often associated with advanced malignancies, particularly gastric and colonic cancers, but they can also result from benign conditions such as peptic ulcers, diverticulitis, pancreatitis, and chronic inflammatory diseases [1].

Gastrocolic fistula can arise as a complication of both chronic relapsing pancreatitis and acute necrotizing pancreatitis [2]. Pancreatic enzymes can erode the walls of adjacent organs, leading to degradation and subsequent fistula formation between the stomach or colon and the pancreas [1]. The direct action of these enzymes on gastrointestinal tissues plays a critical role in this process. Severe inflammation associated with pancreatitis can cause thrombosis in the blood supply and venous drainage to the gastrointestinal tract. This ischemia may lead to tissue necrosis, creating an environment conducive to fistula development [1].

Common symptoms of a gastrocolic fistula may exhibit a classic triad of symptoms, diarrhea, feculent vomiting, and body weight loss, leading to malnutrition, vitamin deficiencies, and electrolyte disturbances [2]. Diagnosing a gastrocolic fistula can be challenging due to its nonspecific presentation. Common diagnostic methods include CT scans with oral contrast, barium enema, and endoscopic evaluations.

The primary treatment for gastrocolic fistulas typically involves surgical intervention. This may include resection of the affected segments of the stomach and colon. In some cases, nutritional support via TPN may be necessary while awaiting surgical correction. Recently, endoscopic management has emerged as a widely accepted initial therapy for treating fistulas, including clips, over-the-scope clip (OTSC) systems, fibrin glue injection, and endoscopic stents, particularly those resulting from benign conditions [3]. This approach utilizes various advanced endoscopic devices, which have significantly improved treatment outcomes and reduced the need for surgical interventions. In our case, the gastrocolic fistula was closed by clips after de-epithelialization with a pleasant outcome.

The authors declare no conflicts of interest.