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Unusual Case of Acquired Gastrocorporeo-duodenal Fistula with Long Luminal Tract Treated without Surgical Operation

Byung Jun Jeon, Seong Hun Kim, In Hee Kim, Sang Wook Kim, Seung Ok Lee, Dae Ghon Kim, Soo Teik Lee

Byung Jun Jeon, Department of Internal Medicine, Gunsan Medical Center, Gunsan, Korea Seong Hun Kim, In Hee Kim, Sang Wook Kim, Seung Ok Lee, Dae Ghon Kim, Soo Teik Lee, Department of Internal Medicine, Research Institute for Medical Science, Chonbuk National University College of Medicine, Jeonju, Korea

Correspondence to: Sang Wook Kim, MD, Department of Internal Medicine, Research Institute for Medical Science, Chonbuk National University College of Medicine, 634-18 Geumam-dong, Dukjin-gu, Jeonju, Chonbuk 561-712, Korea.
clickm@jbnu.ac.kr
Telephone:+82-63-250-2302
Fax:+82-63-254-1609
Received: April 14, 2013
Revised: May 3, 2013
Accepted: May 5, 2013
Published online: July 21, 2013

ABSTRACT

Gastroduodenal fistulas are rare conditions that they occur as either a congenital or acquired condition. The acquired forms usually are associated with peptic ulcer disease; they are mostly located between the gastric antrum and duodenal bulb. We reported the case of 44-year-old male presented with weight loss and melena without any evidence of peritoneal irritation. Endoscopy and CT showed an unusual location of a gastroduodenal fistula between the lesser curvature of the gastric lower body and the duodenal bulb associated with a very large gastric ulcer. The fistula completely closed after one month of medical treatment. Here, the serial endoscopic observations of the unusual case of acquired gastrocorporeo-duodenal fistula and review of literature are reported.

Key words: Acquired; Gastrocorporeo-duodenal fistula; Endoscopy

© 2013 The Authors. Published by ACT Publishing Group Ltd.

Jeon BJ, Kim SH, Kim IE, Kim SW, Lee SO, Kim DG, Lee ST. Unusual Case of Acquired Gastrocorporeo-duodenal Fistula with Long Luminal Tract Treated without Surgical Operation. Journal of Gastroenterology and Hepatology Research 2013; 2(7): 703-705 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/437

INTRODUCTION

Gastroduodenal fistulas usually are found at the lesser curvature of the gastric antrum and duodenal bulb; the incidence is about 0.02%[1]. Both acquired and congenital causes have been reported in patients with gastroduodenal fistulas. If a fistula is acquired, the most common cause is peptic ulcer disease. Here, the serial endoscopic observations of a patient with weight loss and melena are reported; the patient had a very large gastric ulcer and a gastrocorporeo-duodenal fistula with long luninal tract, which was successfully treated by supportive medical care.

CASE REPORT

A 44-year-old-man was admitted to the hospital beacuse of 10 kg weight loss over two months and melena. The physical examination revealed no significant abnormality. The laboratory findings included: a white blood cell count of 8330 /mm3, hemoglobin of 9.8 g/dL, hematocrit of 30.6% and CEA of 1.5 ng/mL. The endoscopy showed a very large open ulcer between the lesser curve of the lower body and duodenal bulb (Figure 1). A gastrografin upper gastrointestinal series also demonstrated a gastrocorporeo-duodenal fistula (Figure 2). A CT scan of the abdomen showed the gastrocorporeo-duodenal fistula with thickening of the antrum in the coronal view (Figure 3). A biopsy was performed on both the gastric and duodenal ulcers and the results revealed Helicobacter pylori infected gastritis with no malignancy. Subsequently, the patient was treated with a proton pump inhibitor (PPI). About one month later, the repeat endoscopy and upper gastrointestinal series showed that the previous fistula opening on both the gastric and duodenal side had completely closed. There was no evidence of fistula formation on the endoscopy (Figure 4) and the upper gastrointestinal series (Figure 5).

DISCUSSION

A gastroduodenal fistula or double pylorus usually develops between the distal stomach and duodenal bulb. The finding of a double pylorus is very rare, it has been reported in about 0.02% to 0.04% with a male predominance[1,2]. This accessory channel can develop congenitally or following penetration of a gastric ulcer into the duodenal bulb[3]. In most cases, a double pylorus is formed as a result of pepic ulcer disease. In this case, the fistula was unusually located between the lesser curvature of the gastric lower body and duodenal bulb; however, most fistulas are found between the antrum and duodenal bulb[4]. Fistula closure in general does not occur spontaneously, and surgical intervention should be considerd in cases with refractory symptoms, recurrent ulcers, and other complications. the fistula opening completely closed just after one month of PPI. The majority of patients have no specific symptoms.6 However, some have symptoms such as epigastric discomfort, dyspepsia, and upper gastrointestinal bleeding[4,5,7]. This case shows rare complication of gastric ulcer with a fistula in an unusual location between the lesser curvature of the lower body and duodenal bulb. We demonstrated the aquired nature of gastroduodenal fistula by serial endoscopic examination.

REFERENCES

1 Kothandaraman KR, Kutty KP, Hawken KA, Barrowman JA. Double pylorus--in evolution. J Clin Gastroenterol 1983; 5: 335-338

2 Hegedus V, Poulsen PE, Reichardt J. The natural history of the double pylorus. Radiology 1978; 126: 29-34

3 Sufian S, Ominsky S, Matsumoto T. Congenital double pylorus. A case report and review of the literature. Gastroenterology 1977; 73: 154-157

4 Hu TH, Tsai TL, Hsu CC, Lu SN, Hsiao M, Changchien CS. Clinical characteristics of double pylorus. Gastrointest Endosc 2001; 54: 464-470

5 Ehrhardt D, Löhr M, Liebe S. Double pylorus as a cause of gastrointestinal bleeding. J R Soc Med 1999; 92: 253-254

6 Graham SM, Lin F, Flowers JL. Symptomatic double pylorus. successful treatment with a biiliary sphincterotome. Surg Endosc 1994; 8: 792–793

7 Lee TH, Park SH. Double pylorus secondary to recurrent ulcer: serial endoscopy follow-up. Endoscopy 2008; 40 Suppl 2:E226. Epub 2008 Sep 25.

Peer reviewer: Kim JH, MD, PhD, Department of Gastroenterology, Ajou University School of Medicine, San 5, Woncheon-dong, Yeongtong-gu, Suwon 442-380, Korea.

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