gastrojejunocolic fistula ( gjf ) is a rare and late complication of the surgical technique of gastrectomy and gastrojejunostomy applied for recurrent peptic ulcer disease .
generally gjf is considered to be induced by a stomal ulcer due to inadequate gastric resection , incompleteness of vagotomy and long afferent loop .
the most frequent symptoms of such a fistula are upper abdominal pain , severe weight loss , diarrhea , gastrointestinal bleeding and sometimes fecal vomiting .
the diagnosis is most reliably and frequently made by barium enema and gastroscopy . in the management of the gjf ,
the historical approach was 2 - 3-phased operations which included colostomy in order to ameliorate the nutritional status and minimize the mortality of the patient .
however today , because of improved parenteral and enteral support treatments and the developments in intensive care conditions , single - stage procedures can be applied and these have been favored to minimize mortality . although the occurence of gjf has decreased remarkably as a result of better medical treatment , the modern management of this condition and the generally accepted surgical treatment strategies must be discussed .
a 51-year - old man was admitted to the surgical unit of yuksek ihtisas hospital in october 2006 with complaints of chronic diarrhea , epigastric pain and discomfort , severe weight loss and weakness .
his medical history was marked by a gastroenterostomy due to duodenal ulcer disease in 1992 .
the patient was cachectic and dehydrated . at physical examination , liquidated intestine loops were sensed in the epigastrium and upper right quadrant .
a complete blood count revealed a hemoglobin level of 10.3 g / dl ( normal range 10.016.0 ) and an albumin level of 2.1 g / dl ( normal range 3.44.8 ) in the electrolyte values , the blood sodium level was 132
upper gastrointestinal series assessment confirmed the passage between the corpus of the stomach and the proximal jejunum ( fig .
1 ) . transabdominal ultrasonography and tomography showed liquidated small intestine with edema and liquid between the intestine loops ( fig .
2 ) . gastroscopy showed a previous gastrojejunostomy and a fecaloid secretion from the anastomotic region of the lumen .
colonoscopy showed an ulcer mass obstructing the transverse colon lumen and preventing the endoscope from passing to the proximal region .
total parenteral nutrition ( tpn ) was started immediately and continued in the postoperative period till the albumin level returned to normal . after improving his state of malnutrition ,
the patient was taken into the operation room and an exploratory laparotomy was undertaken . at surgery ,
a radical en bloc resection was performed involving a subtotal gastrectomy , posterior vagectomy , partial transverse colon and jejunum resection .
recovery was uneventful and the patient remained well at follow - up ; once his general status had improved , he was taken into the normal service .
today , the surgical operation necessity for peptic ulcer disease has decreased dramatically . especially developments in the medical treatments with the usage of h2 receptor blockers , proton pump inhibitors and the eradication regimes for helicobacter pylori play an active role .
so the incidence rate of these fistulas has been remarkably lowered because of the decrease in surgery .
since fistula formation needs a 20 - 30-year latent period after the initial surgery , this severe and rare complication may occur presently .
therefore , gjf is still an important and current complication [ 2 , 3 , 9 ] .
the symptoms of gjf are diarrhea with lienteric stools , epigastric pain and discomfort , gastrointestinal bleeding , feculent eructation , fecal vomiting , weight loss and weakness .
the most frequently used diagnostic tools are barium enema and endoscopy [ 1 , 11 , 12 , 13 ] .
the success rate of barium enema in correctly diagnosing the fistula is approximately 95 - 100% [ 10 , 12 , 13 ] .
however , its determination success in the phenomenons which are related to malignancy is low .
computerized axial tomography is used to determine this complex fistula and to exlude extraluminal diseases that may define underlying etiology .
especially the fistula orifice can be followed by upper gastrointestinal system endoscopy and when necessary , preoperative histological confirmation can be done .
because of the fading effect of the disease , in the postoperative period , careful clinical and laboratory evaluation must be carried out . as specified before ,
in a large majority of these patients , the physical examinations and laboratory studies reveal low to medium malnutrition , anemia and electrolyte imbalance . as soon as possible
therefore , tpn or total enteral nutrition ( ten ) should be administered in patients who are suffering from malnutrition and this treatment protocol should continue in the postoperative period .
because of the physiologic effects of ten over tpn , it should be the first choice if a nasoenteric tube can be placed into the jejunum .
the surgical options and treatments of gastrocolic fistula / gjf have changed over the years .
the historical approach was 2 - 3-staged operations even involving a preliminary diversion colostomy in order to ameliorate the nutritional status of the patient and to decrease mortality [ 4 , 6 , 7 ] . in the late 1930s ,
the three - staged procedures included ( 1 ) colostomy , ( 2 ) resection of the fistula and ( 3 ) colostomy closure .
this operation , which is known as lahey 's procedure , was very popular because it was done with lower morbidity and mortality .
in the 1960s , it was stated that single - stage procedures could be applied . today , because of the parenteral and enteral support treatments and the developments in intensive care conditions , one - stage resection can be applied , and the mortality rates are getting lower [ 2 , 3 , 8 , 21 , 22 ] . in conclusion , as a result of developments of the agents used in peptic ulcer treatment , gjf incidence has decreased dramatically . in the ancient times , recovering the medical status and staged operations were applied in gjf treatment , but today one - stage resections are preferred if the general status of the patient is suitable .
tpn or ten should be administered in patients suffering from malnutrition . in the preoperative diagnosis stage , a possible malignancy must be eliminated .
 we herein report the case of a 51-year - old man with gastrojejunocolic fistula . 
 it is one of the late severe complications of gastrectomy and gastrojejunostomy and is considered to be induced by a stomal ulcer due to inadequate resection of the stomach and incompleteness of vagotomy . 
 the main clinical presentation of this condition is chronic abdominal pain , weight loss , diarrhea , gastrointestinal bleeding and fecal vomiting . 
 the diagnostic workup should include barium enema , gastroscopy and sometimes colonoscopy and abdominal tomography for excluding and ruling out the possibility of malignant extraluminal disease . 
 the historical approach of the treatment of this rare entity was 23-phased operations which included colostomy . 
 however today , medical management has recently been recommended as the first - line therapy , with parenteral and enteral support treatments . 
 the preferred surgical approach is single - stage gastrocolic resection and anastomosis and this has been favored to minimize mortality . 
Introduction
Case Report
Discussion