Gastrocolocutaneous fistula is a rare complication of the percutaneous endoscopic gastrostomy (PEG) procedure. Typical symptoms usually occur in the first few months. We recently encountered 2 patients with 8- and 33-month asymptomatic periods. A 74-year-old man presented with watery diarrhea for 1 month. He had undergone PEG 9 months earlier. During workup, an upper endoscopy and abdominal CT scan revealed the migration of the feeding tube into the transverse colon. He was discharged with a nasogastric tube after treatment. A 77-year-old man presented with sudden loosening of his PEG tube with a duration over 3 days. He had undergone PEG procedure three times until that time. During workup, a gastrocolocutaneous fistula was diagnosed. However, when previous studies were reviewed, an abdominal CT scan, which was done 6 months ago before the third PEG, showed the fistula already existed at that time, suggesting that it was created about 33 months earlier when he underwent the second PEG procedure. The patient died of pneumonia aggravation despite conservative treatment. Both a high index of suspicion and the careful inspection of the upper endoscopy are very important for early diagnosis regardless of symptoms.
Percutaneous endoscopic gastrostomy (PEG) is commonly used for long-term enteral feeding for patients who are unable to swallow. PEG is usually considered a safe procedure associated with low mortality and a low rate of significant complications.
A 74-year-old man with a history of cerebral infarction was admitted with watery diarrhea that had lasted for 1 month. PEG had been performed 9 months prior to this admission. The patient's condition had been stable for 8 months after PEG. Vital signs and laboratory results upon admission were as follows: blood pressure, 80/40 mmHg; body temperature, 36.8℃; white blood cell count, 18,300/µL; hemoglobin level, 13.2 g/dL; BUN level, 10.3 mg/dL; creatinine level, 0.9 mg/dL; urine white blood cell count, high. His septic condition improved after adequate hydration and the administration of broad-spectrum antibiotics. However, the postprandial watery diarrhea persisted. On the 12th day of hospitalization, an upper endoscopy revealed a gastrocolic fistula and the internal bumper of the PEG tube was not seen (
A 77-year-old man with a history of alcoholic dementia and intracerebral hemorrhage was referred by a nursing home to undergo an exchange of feeding tubes because his tube had suddenly loosened 3 days previously. He had undergone a PEG procedure 3 times and a simple exchange of PEG tubes twice. The first PEG procedure was performed 33 months earlier for enteral feeding. The second PEG procedure was performed 2 weeks after the first because the patient had forcibly pulled out the initial feeding tube. The second PEG procedure had to be newly done because the tract of the first PEG site was obstructed shortly. The site of the second PEG was close by the first PEG site. The patient's condition was stable for 27 months after the second PEG procedure was done. The third PEG procedure was performed 6 months prior to this consultation owing to buried-bumper syndrome. At that time, the patient presented with a loosened tube and abdominal pain. Because an upper endoscopy revealed that the feeding tube bumper was buried in the gastric wall (
The exact mechanism of gastrocolocutaneous fistula is not well known. However, the most plausible theory is the interposition of the colon, usually the splenic flexure, between the anterior abdominal wall and the gastric wall.
The leakage of gastric contents through the gastrocolic fistula into the colon leads to typical symptoms such as presence of diarrhea that contains food. The reverse condition causes feculent vomiting and the appearance of fecal material.
Techniques using both transillumination and finger pressure as a guide to place the puncture site are useful for preventing this complication. Guidance by ultrasound or CT can be used selectively but may have limited benefit. A study by Foutch et al.
This complication can be fatal if it is not detected early and managed properly.
Historically, the key treatment for gastrocolocutaneous fistula was to allow the fistula to close after the feeding tube was removed. Recently, endoscopic treatment of fistulas has been attempted, although surgery is often required.
In summary, the 3 key take-home messages from our cases are as follows. First, some techniques (such as transillumination, aspirating syringe usage, and application of a small amount of insufflated air) are helpful for preventing fistulas. Second, a careful inspection of the upper endoscopy in patients with typical symptoms is useful for early diagnosis. Finally, if typical upper endoscopic findings, such as fecal material attached to the PEG bumper, a bluish shadow, colonic haustra, or buried bumper, are observed, the possibility of a gastrocolocutaneous fistula must be considered.
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Gastric and colonic view of fistula. (A) Upper endoscopy revealed a gastrocolic fistula and no visible bumper of the internal percutaneous endoscopic gastrostomy (PEG) tube. (B) Colonoscopy revealed a gastrocolic fistula in the transverse colon. (C) Three metal clips were successfully placed at the gastrocolic fistula opening during colonoscopy. The red arrow indicates the colocutaneous fistula opening, which remained under observation for spontaneous closure.
Abdominal CT findings. (A) The bumper of the feeding tube that migrated into the colonic lumen (axial view). (B) The white arrow indicates the fistula's tract between A B the stomach and colon (sagittal view).
Endoscopic sealing of the fistula. A radiologic study with gastrografin administered through a nasogastric tube was performed 1 week after the colonoscopic metal clipping. There was no leakage of dye from the stomach. The white arrow indicates the previous metal clips located at the colonic opening of the gastrocolic fistula.
Upper endoscopic findings. (A) An upper endoscopy which was done 6 months ago. The gastrocolocutaneous fistula was misdiagnosed as buried-bumper syndrome 6 months previously. (B) An upper endoscopy which was done at this time. The bumper of the feeding tube was deeply buried within the gastric wall and had formed a hole at the time of the patient's admission to our hospital. (C) The bumper with fecal material observed through the gastrocolic fistula. A large space was observed when the scope was advanced into the hole, and brownish material was attached to the bumper. (D) The colonic lumen observed through the gastrocolic fistula. The colonic lumen was identified by a bluish liver shadow and colonic haustra, 3 weeks later.
Schematic diagrams of the 3 stages based on the position of the bumper in Case 2. (A) The gastrocolocutaneous fistula was created during the percutaneous endoscopic gastrostomy (PEG) placement, and the transverse colon was pressed tightly between the stomach and the abdominal wall (the first stage). (B) During the intervening period, the transmural migration of the feeding tube showed endoscopic findings similar to those of buried-bumper syndrome (the second stage). (C) The bumper migrated into the intracolonic space through the gastrocolic fistula (the third stage).