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BENIGN DUODENOCOLIC FISTULA

Rajeev M Joshi*, Ashutosh Darbari**, Prasad K Wagle***
*Associate Professor; **Resident; ***Lecturer, Department of Surgery, BYL Nair Charitable Hospital.
Benign duodenocolic fistula is a rare entity. We present here a case of a 36 year old male patient who presented with history of passing undigested food in the faeces and faecal eructations and loss of weight and was diagnosed to have a duodenocolic fistula secondary to a duodenal ulcer. Patient underwent an exploratory laparotomy with division of the fistula

CASE REPORT

Thirty six year old man, habitual alcoholic, presented with history of passing undigested food in the faeces and faecal eructations and loss of weight since four to five months. The patient gave history of urgency for passing stools. There was no history of passing blood in stools. The patient had undergone emergency exploratory laparotomy for duodenal ulcer perforation twice five and two years ago. The details of the surgical procedures and medical treatment were not available. During the present hospitalization, he was found to be dehydrated, anaemic and malnourished. His vital parameters were normal. Examination of the abdomen was unremarkable. Investigations revealed haemoglobin to be 9.1 gms/dl, total proteins 5 gms/dl with albumin of 1.8 gms/dl. His BUN and serum creatinine were normal. The X-ray of the abdomen was normal. A barium meal study of stomach and duodenum showed rapid transit of barium from first part of duodenum into the hepatic flexure of colon (Fig. 1). The stomach and the rest of the duodenum was normal. An upper G.I. endoscopy showed a fistulous opening in the first part of duodenum in communication with transverse colon. There was no evidence of active peptic ulcer or malignancy.

Preoperative preparation included correction of dehydration and anaemia. The bowel preparation was done with oral mannitol and evacuant enemas. Laparotomy through the previous supra umbilical midline incision revealed multiple adhesions between the abdominal wall and the small bowel. These adhesions were divided to expose transverse colon and the duodenum. The transverse colon just distal to the hepatic flexure was found adherent to the first portion of duodenum. The duodenum was mobilised by Kocher's manoeuvre and right side of the colon was mobilised by dividing the lateral peritoneal attachments. This exposure allowed definition of the site of fistula that extended from lateral wall of the first part of duodenum to the hepatic flexure of colon. The rest of the colon and abdominal viscera were normal. Truncal vagotomy was carried out. The fistula was divided between intestinal clamps and the defect in the duodenum was sutured in two layers with silk sutures. The edges of the opening in the colon were freshened and the defect was sutured transversely in two layers with silk sutures. Anterior isoperistaltic antecolic gastrojejunostomy with short afferent loop was done as a drainage procedure. The omentum was interposed between hepatic flexure of the colon and the duodenum. A tube drain was left in hepatorenal pouch of Morrison.

Fig 1 : A barium meal study of stomach and duodenum showed rapid transit of barium from first part of duodenum into the hepatic flexure of colon.

The patient developed intestinal obstruction on the 12th post operative day that responded well to conservative treatment. The patient was last seen six months post operative at which time he was asymptomatic and had gained 10 Kg weight. The follow up barium study done showed no evidence of fistula. The histopathology of fistulous tract revealed evidence of chronic non specific inflammation with no evidence of tuberculosis and malignancy.

DISCUSSION

Benign duodenocolic fistulas, less common than the malignant counterpart which are caused by perforating colonic carcinomas, may be secondary to peptic ulcer disease,[1] biliary tract disease,[2] ulcerative colitis,[3] appendicitis,[3] regional enteritis,[4] caseating tuberculous lymph node,[5] perforated duodenal diverticulum,[6] syphilis, ingestion of foreign body and ruptured typhoid ulcer or even spontaneous. Ruptured duodenal ulcer was commonly reported as the cause of benign duodenocolic fistula.[1] However duodenocolic fistula as a complication of duodenal ulcer is extremely rare, though first reported by Sanderson as early as (1863);[7] the part of colon often involved in a benign duodenocolic fistula is the hepatic flexure of colon and proximal transverse colon. Fistula of first part of duodenum is often associated with peptic ulcer and cholelithiasis.[7] Fistula of second and third part of duodenum is often associated with inflammatory colonic disorders due to close proximity of duodenum to the colon.[7] The most prominent features of benign duodenocolic fistula are diarrhoea, weightloss and faecal vomiting. Reflux of faeces into the duodenum leads to jejunitis and alteration of intestinal flora. Jejunitis reduces the absorption of iron, glucose and folic acid and alteration of ileal flora leads to vit B12 malabsorbtion.[8]

From a review of surgical procedures which have been used successfully in the treatment of benign duodenocolic fistula, it is appropriate that the simple excision and closure of the origins of fistula is sufficient. The patient had intractable peptic ulcer with perforation for which he was operated twice at which time only simple suturing was carried out. A definitive surgery at the time of second operation would have prevented the development of duodenocolic fistula.

REFERENCES
  1. Herrington JL. Duodenocolic fistula with perforation secondary to peptic ulcer. Am J Sur 1967; 113 : 285-8.
  2. Neville WE. Duodenocolic fistula due to acute cholecystitis. Am J Sur 1954; 87 : 300.
  3. Clayton, Thornton. Benign duodenocolic fistula - Review of the literature and case report. Am J Sur 1953; 60 : 832-6.
  4. Holzbach RT, Jones JE. Severe regional enteritis with a unique duodenosigmoid fistula following normal pregnancy. Am J Gastroenterol 1969; 52 : 49-52.
  5. Oglive H. Nonmalignant duodenocolic fistula. Am Sur 1950; 131 : 899.
  6. Kellum JM, Boucher JK, Ballinger WF. Serosal patch repair of benign duodenocolic fistula secondary to duodenal diverticulum. Am J Sur 1976; 131 : 607.
  7. Brindle MJ, Kane JF. Benign duodenocolic fistula. Br J Sur 1966; 53 : 749-53.
  8. John MT, Howat, Schofield PF. Benign duodenocolic fistula. Bri J Sur 1978; 65 : 513-5.
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