Gastrocutaneous fistula: case report and literature

Grand Rounds Vol 8 pages 10–13
Speciality: Breast Surgery, gastroenterology;
General Surgery
Article Type: Case Report
DOI: 10.1102/1470-5206.2008.0004
Gastrocutaneous fistula: case report
and literature review
Alex Hotouras, Adhip Mandal, Veera Karri and Aarti Varma
United Lincolnshire Hospitals NHS Trust, Lincolnshire, UK
Corresponding address: Dr Alex Hotouras, Department of General Surgery,
Grantham and District Hospital, Grantham, Lincs, UK.
E-mail: [email protected]
Date accepted for publication 21 January 2008
Abstract
We report the case of a 91-year-old lady who presented with a gastrocutaneous fistula in the
absence of any recent surgery. We review the literature and discuss this uncommon surgical
problem.
Keywords
Gastrocutaneous fistula; gastric ulcer.
Case report
A 91-year-old lady presented with a 2-week history of pain over the left anterior chest
wall. She described ‘‘foul-smelling’’ nipple discharge which was not blood-stained. She
was treated by her GP with antibiotics but the pain gradually worsened and she was now
describing a ‘‘whistling’’ noise when discharging. Her past medical history included a gastric
ulcer and a left mastectomy carried out 30 years ago for carcinoma of the breast. She did report
having problems with the healing of the mastectomy scar but a biopsy done 3 years previously
was clear.
On examination, there was significant erythema around the left anterior chest wall with
pus discharging from a small hole measuring 0.5 mm 0.5 mm (Fig. 1). Her chest radiograph
(Fig. 2) revealed shadowing in the left subchondral space but the lung fields were clear.
A provisional diagnosis of chest wall abscess was made and she was started on intravenous
antibiotics. On the following day undigested food was discharged from the left anterior chest wall
(Fig. 3). An oesophageal/gastrocutaneous fistula was suspected and she underwent a computed
tomography (CT) scan with contrast of her chest and abdomen (Fig. 4).
The CT scan demonstrated a soft tissue abnormality along the left anterior chest wall
communicating with the underlying greater curvature of the stomach. The findings were
consistent with suspected chest wall abscess communicating with the stomach. She also
underwent gastroscopy which demonstrated an ulcer associated with a fistula approximately
1 cm in diameter. Multiple biopsies were sent for histopathological examination which did not
reveal any evidence of malignancy. She eventually underwent excision of the ulcer and the fistula
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Gastrocutaneous fistula
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and the defect was repaired with a myocutaneous flap. Histological examination of the
excised specimen confirmed the presence of active chronic inflammation of the gastric
mucosa but there was no evidence of Helicobacter pylori infection, dysplasia or neoplasia.
Section of the skin showed extensive necrotic ulceration and the dermis displayed elastotic
degeneration and active chronic inflammation and fibrosis. The adipose tissue also revealed
focal fat necrosis.
Her post-operative recovery was uneventful and a gastrograffin swallow did not reveal any
abnormalities. The patient was reviewed in the outpatient clinic after 2 months and she was
eventually discharged from follow up. The full diagnosis was gastrocutaneous fistula associated
with benign gastric ulcer.
Fig. 1. Left anterior chest wall cellulitis and a small defect can be seen.
Fig. 2. Chest radiograph demonstrating left subchondral shadowing.
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A. Hotouras et al.
Fig. 3. Undigested food material discharged via a gastrocutaneous fistula.
Fig. 4. Computerised tomography showing communication between the stomach and anterior chest wall.
Discussion
A fistula is a well documented but infrequent surgical complication that requires prompt
diagnosis as it can increase patient morbidity and mortality[1]. Reviews of gastrointestinal fistulae
have shown that pure gastrocutaneous fistulae are uncommon with an incidence ranging
between 2% and 20%[2]. The vast majority usually involve the greater curvature of the gastric
fundus following surgery. In particular, they are most likely to arise from leakage of
gastroduodenal or gastrojejunal anastomosis after gastrectomy or following splenectomy[2,3].
Gastrocutaneous fistulae may also be seen after removal of long standing gastrectomy
tubes, especially in the paediatric population[4]. The defect does not close spontaneously
if the gastrostomy has been used for a long time, if there is delayed gastric emptying/
obstruction, foreign body (e.g. silk suture which should be avoided when constructing a
gastrostomy), or associated chronic granulomatous disease such as Crohn’s[4,5]. The presence of
Gastrocutaneous fistula
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a gastrostomy tube for more than 9 months is associated with a 45% incidence of gastrocutaneous
fistula[5].
In our case, there was no history of recent surgery so the most likely cause of the fistula
appears to be her benign gastric ulcer causing chronic inflammation and tissue erosion. This is a
rare presentation and, we believe, has been reported in the literature only once previously[2].
The aetiology of gastric fistulae is not well understood. Ischaemic gastric necrosis has been
postulated as playing an important role in the development of gastrocutaneous fistulae but it has
never been conclusively proven in the clinical setting[2]. In the case reported here, histopathological examination showed chronic inflammation of the gastric mucosa and necrosis of the skin
and subcutaneous fat so devascularisation secondary to chronic inflammation appears to be
implicated in the pathogenesis of a fistula.
The initial management of a gastrocutaneous fistula aims to increase gastric emptying
(e.g. metochlopramide), increase gastric pH (e.g. lansoprazole) and decrease intragastric
pressure[4,6]. Kobak and colleagues reported a 53% fistula closure rate following tract
cauterisation with silver nitrate and use of H2 antagonist[4]. Deruyter et al. reported two
successful cases of fistula closure with omeprazole and total parenteral nutrition[7].
Pearlstein and colleagues reported spontaneous closure of gastrocutaneous fistulae in 70% of
patients with conservative measures[2]. More recently, other researchers reported fistula closure
with minimally invasive procedures such as the application of endoclips, fibrin glue or collagen
plugs[6,8,9]. In addition, Makris and Sheiman reported fistula closure using a three-step technique:
(1) cauterisation of the fistula with silver nitrate to denude the tract of its epithelial lining;
(2) mechanical obliteration with Gelfoam pledgets; and (3) tract sclerosis using betadine[10].
Invariably, there will be a certain number of gastrocutaneous fistulae refractive to medical
management or minimally invasive procedures. In those cases, surgical excision is indicated[2,6].
Teaching point
In the absence of malignant disease or gastric outlet obstruction, gastrocutaneous fistulae should
be managed non-operatively. Spontaneous closure can be anticipated for the majority of cases
within a few weeks. Surgical excision should be reserved for gastrocutaneous fistulae intractable
to other forms of therapy.
References
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imaging evaluation. Radiology 2002; 224:9–23.
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187:223–226.
3. Bryk D, Petigrow N. Post -splenectomy gastric perforation. Surgery 1967; 61: 239.
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endoscopic gastrostomy tubes in children. J Pediatr Gastroenterol Nutr 2000; 30:404–7.
5. Gordon JM, Langer JC. Gastrocutaneous fistula in children after removal of gastrostomy tube:
incidence and predictive factors. J Pediatr Surg 1999; 34:1345–6.
6. Siddiqui A, Kowalski T, Cohen S. Closure of a non healing gastrocutaneous fistula using an
endoscopic clip. South Med J 2007; 100:75–76.
7. Deruyter L, Van Blerk M, Cadiere GB, et al. Treatment of high-output gastric fistulas with
omeprazole. Hepatogastroenterology 1991; 38:83–86.
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percutaneous management with a collagen plug. J Am Coll Surg 2000; 190:588–92.
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tube removal. J Vasc Interv Radiol 2002; 13:205–7.