Dorr, TW

Meyer, WH

Starzl, TE

Meyer Jr, WH

Name not available

Benign duodenocolic fistula

D-Scholarship@Pitt

ntl Simeone, Inn, Ed. J, 952. ck. R. H.: : c t a y  wit11 i Sex Func- 51. R. E.: Thc tic Nervous I Ijt.11 ig11 Doodenocolic. Fistula THOMAS E. STARZL. Ph.D., M.D.. M i a m i .  Fls.: T H O M A S  W. QORR, M.D., lampa, $la., and I WILLIAM H. M E I E R  Jr., M.D., M i a m i ,  Fla. I ! I)~~i~tlt . l~ocolic fistulas arc utlroliitnoil atltl ,!rc liiost f rcque l~ t ly  secontlar!. to  carcino~n;l ,,i (he c o l o n . ~ u o t l e n w o I i c  fistula due t o  f ,111 ut~derlying h e n i p  disease is very  rare, i lie world literature containing accounts of 1 , , I I I ~  23 such cases. I It is the purpose of  this report  t o  docu- lll~llt a n  additional case of  benign duodeno- ,.olic fistula, which w a s  thought t o  have /mn a complicatiorl of a duodenal ulcer, nntl to review the clinical features, etiology, ,,nthogenesis, a n d  treatment of this a n d  the  I,rr\.iou~ly described cases. Subnntted for publicatian Nov. 14, 1958. l'rsent address (Dr. Starzl) : Department of , S~lrpery, Northwestern University hledical School, Cl~icago. U. S. Public Health Service Trainee So. 904 (Dr. Meyer). Fmn the Department of Surgery, University of 1Iian1i School of hiedicine, Coral Gables, Fla, .lnd the Department of Radiology and Surgery, Tampa General Hospital, Tampa, Fla. R e p o r t  of a Case A (A-year-oltl white wcmian was atlmittcd to the surgical service on Oct. 15, 1957, with ~Mcnninal pain. vo~uiting, and weight loss. She had been well and tvitliout gastrointestirlal complaints tlntil six niontlls before adn~issiol~. At this time she tlevel- oped epigastric pain, which gradually became con- tinuous and which was not related to food ingestion. One month before admission she developed persistent nausea with marked increase in epigastric pain. Shortly thereafter, she described the onset of vomiting of foul-smelling material and in- variably provoked by eating. Three weeks before admission the pain shifted to the right upper quadrant, with radiation to the tip of the right scapula. During the two weeks preceding adnis- sion she suffered from chills, fever, and night sweats. She had lost a large but undetermined amount of weight. For 10 days prior to admission she had been in another hospital, where she received supportive care. She did not have diarrhea at any time during the illness. Physical Examktwn.-The patient was an emaciated, dehydrated white woman, who appeared to be chronically ill. Temperature was 38.4 C 1 8ARlUM ENEMA (EVACUATION) 10- 16- 57 Figure 1 117/611 I A. M .  A. ARCHIVES 01; .PURGE/,'}. , (101.1 F ) .  Abtlo~iiinal examination revcllcd tender- of nialignancy either in the colon or in the uppr ncss in tile right mid- and u p p r  abdomen with gastrointestinal tract. Except for the fistula, the involuntary muscle spasm. No definite mass could only abnormality was a duodenal ulcer, from wliirll be felt. The rest of the physical examination was the fistula seemed to originate (Fig. 3). csset~tially ~lonnal. Course in Hospital.-A blood transfusion of Lobnrcztory Data.-Urinalysis normal. He~no- 1,000 c c  was given prwperatively. A 48-llo11r grnni: Hbg 8.8 gm. %; hematocrit 30%, and neomycin bowel preparation was carried out ant1 2 \VnC 14,350 per cubic millimeter. BUN, COS, Miller-Abbott tube passed into the jejunum. 011 chloritles, hilirubin, amylase, alkaline phosphatase, Oct. 18 she was taken to the operating room and m d  thyniol turbidity were normal. The chest x-ray the upper abdominal abscess drained through a was nonnal. right subcostal incision. The free peritoneal cavity A harium enema study was performed. As the was not entered. The abscess involved the suh- dye reached the hepatic flexure, it passed outside hepatic and anterior subphrenic spaces, which the lun~en into a fistulous tract which communicated communicated around the lateral margin of the with a large right subphrenic abscess and with the right lobe of the liver. It was not possible to second portion of the duodenum (Fig. 1). A identify any fistulous openings, altl~ough the gastrointestinal series confirmed the presence of abscess cavity contained a large amount of barium, the triple fistula (Fig. 2).  There was no evidence feces, and bile-stained duodenal contents. The pseudodiverticulurn and central crater Figure 3 - TABLE 2.-Biliary Disease . Am, Phpslesl X-Ray Locntlon of AnWr Yr. Complaints Duntlon Flndlnr  Dlagnosls Flstula Therapy Outcome CommentJ 1. IP*U I 55 Paln, vomlt- 3 mo. Emeelstlon; Baenema and Rlght transverse Exclslon flstuln; Owd Prwvlously known to hare d.M7) IW, RUQ tender- 0.1. serles both colon to 1st part gastroenteros. cholecystltls + wekht Lola - neS showed tlstula of duodenum to tomy: dralnage gallbladder subphrenlc ah- SeCSS 2 Eueallle 81 Paln Not stated Not stated Ba enema showed Trnnsverse colon Cholecystectomy; a w d  (I=) dstula, 0.1. to 2cl part of closure of fistula mries not done duodenum to gallblnddcr 8. Narllle I *  Not Paln, vomit 1 at. RUQ tender- Ba enemn showed IIcpr~tic fle~urc to Cholecystectomy; Oood Had chronlc cholccsstltis (1064) stated lng, and nes htula: 0.1. 2d part 01 duo- segmental colon lor yean - weight lo= series not done drnum lo gnll- resectlon; closure bladder ot duodenal a t d a  4. Rmenqvlst 61 Paln. diarrhea 2 mo. Not stated Ba enema showed Right transverse Cholecystectomy; aood Syniptoms of cholcss3- 4 Bbherg*' and welght llstula; gall- colon to 1st p u t  cxclslon Bstula tltls lor 9 yr. (1956) loss bladder dld not 01 duorlen~~m to ~Isusllre; 0.1 .  gl~iiblndder m%m not done 8. PlaUner & i6 Palo, vomlt- 4 yr. Not stated Ba enemn and Right trnnsvcm Xot operated Allve FLstula persbtesl on r- Ooldxhlay 1' lng, dlnrrhca 0.1. serles both colon to 1st part rays tnken over 4-yr. (1W) and weight showed BsttJa: of duodenum to pr tod IOU dblaclder  dld cilllhln~ldcr not vhuallre < TABLE 4.-Miscellaneotcs Causes Am. LPChor Yr. Complaints Duratlon 1. - 1 )  82 Epigastric paln, 8 mo. (003a) vom:tIng, and welght low 2. W t l e  1 * 52 Dlamhea and 32 yr. (Inter- mJO) weight loss mittent symptoms) S. OdCvle I 1 54 Vomitlug. 3 mo. c3sao) diarrhea, and welght loss 4. m e l d  8 :  Not Dlarrhea ant1 Xot stated @St) stated welght loss 5. Baalllo I 43  Vomiting, G nlo. tW52) diarrhea. fever, welght loss, and RUQ psln Upper abdom- Ba enema not Transversa colon lnal tenderoesa done; 0. I. s e e  to Zd part of rled sbowed bar- duodenum lurn reflux Into b W  ~ ~ e s  Emnclntlon Ba enema and Ascending colon 0. I. sertes both to 3d part ol showed llstuls duodenum Emaclatlon Ba enemn showed Ascendhg colon to Ltula; 0. I. 3d part of mrles not done duodenum So t  stntcd Ba enemn showed Slgmoid colon to astula; 0. I. duodenum serles dld not show tlstula RUQ and flank l3n enemn showed Right trnnsvem tenderness; flstuln colon to 2d part emaelatlon of duodenum Therapy Outcome Cornmenti Closure of tlstula Owd Thought by author lo be due to typhoid 3? yr. prevlously Closure ol flstula Owd C ~ s n t l n g  node lound in relatlon to Bstuls w s  thought by author to be the muse Closure 01 flstula Oood C m a t h g  node found in reiatlon to Bstuln thought by author to be the cause Closure 01 flstula S o t  S o  erplnnation nd r sn t~d  stated lor flstuls Closure of flatuln Owd Injury to colon and duo- denum occurred ti mo. prevlously s t  siirycry: tlstula occurmd through sites of rcp~ir  ol these lnjtrrit~s 8. Ranqv l s t  Vomltlng, 1 yr. Not stated Baenen~n showed Rlght tronsvetse Closure of fistula Owd Thullpht by null~ors 11) he 4 q b e r g  1' dlarrl~m, nncl dstula; 0. I. colon to 2d pnrt due to p+rfor:~tlou of 1IJJ) weight loss series not done 01 duodenum foreign hody; 110 h~r. elga body wcovere<l , ; , , ll~c tvcrc lcft i l l  the sr~l~pl~rn~ic alltl s111~I1cp~tic . I , : l ~ ~ ~ ,  anti 1 s~itnp dr:tin ~ v n s  ~)lacetl in the ~ l l l ~ l ~ r p n l ~ c  Spncr. The \vor l~~ t l  was left open. I I titer tlris ~~rordnre, hcr c rn ld i t io~~  rnpitlly ,,llprovctl. l ~ ~ i t i a l l y ,  there was a proiclse cliscl~arce ' ,,i l / ~~ rwle~~a l  contcnts into tlre sump drain, but this rr:lccrl ahrtlptly after 36 Ilorlrs. The Miller-Ahbott lllls \V;IS mplnycd for feeding purposes for a few ,Invc pnstopcmtively, after \\4licl1 she resunled ,,r:~l fcnlings. The suhpllrenic abscesses responded r:llti~ll!. to a regimen of multiple Bushings with )11,lro~rn proxitle solution. ~l;lrvcn days after surgery, the barium enema {\a< rcpcateci and the finclings iorrntl to he entirely normal. A repeat gastrointestinal series confirmed tllc presence of duodenal ulcer with closure of tile fi5t11la. A sr~bsequent cllolecystogram revealed a normal gallbladder. She was discharged on the 1?1I1 postoperative day. As an outpatient, the granulating subcostal tvorlnd closed rapidly and nine weeks after surgery was completely healed. She has been maintained on an ulcer diet and has gained 25 Ib. Follow-up x-ray studies were obtained in May, 1958, seven months after surgery. Barium enema findings were normal. A gastrointestinal series showed a de- fornied duodenal bulb, but no ulcer crater could be tlemonstrated. Comment The etiology of benign duode~iocolic fis- tula is varied. More than half the reported cases have been complications of duodenal ulcer (eight cases, Table 1) or gallbladder disease (five cases, Table 2 ) .  Three fistulas were secondary to ulcerative colitis, and two followed acute appendicitis (Table 3). Other causes were a typhoid ulcer, tuber- culous adenitis, operative trauma, and for- eign-body perforation (Table 4). The patients with duodenocolic fistula ranged in age from 12 to 81 years. They presented with two groups of complaints: those referable to the fistula and those due to the underlying disease. Symptoms ex- plainable on the basis of the fistula showed i considerable uniformity irrespective of the etiology. All patients had weight loss ex- cept one (and in this case the fistula had been present for only one week). The I magnitude of weight loss was usually im- I pressive, being as much as 100 lb. In 14 of the 24 reported cases there was vomit- 1 ing. and frequently this was fecal in char- ! .qtarz[ et a,. I actcr . - r \9c~~tec~i  hntl tli;~rrlic.;~, ; t r i t l  i t1  a numl)cr of case.; the fcccs corit;~it~ctl utitli- gestetl footl. Thirtecn pnticnts .hat1 uljpcr abt1ornin;ll pain, which w;is usr1;tlly loratcd it1 the right hypochontlrium. 7.11~: tlurntior~ of the fistulas was 1 ~vcck to 32 years. The outstanding physical firltling in these patients was emaciation. which was present in all docn~nentcd cases but one. Tcrider- ness over the site of the fistula was present in slightly less than one-half the cases. In a few instances a mass was palpable, and this was usually indicative of an abscess which communicated with the fistulous tract. Eighteen of the patients had a barium enema, and in each instance the fistula was demonstrated. In 14 cases a gastrointes- tinal series was done, but the fistula was seen in only 6 of these. The lack of success in demonstrating the fistulas with antegrade dye studies lends support to the concept l" that the diarrhea is partly due to retrograde fecal flow through the fistula, with a result- ant jejunitis or duodenitis. In  the group of fistulas associated with duodenal ulcer (Table I ) ,  some cases had a history suggestive of acute duodenal per- foration. Symptoms of the fistula appeared shortly thereafter,Ov10 and in these cases it is probable that a subhepatic abscess formed, which secondarily perforated into the colon. This is the probable pathogenesis in the present case. In other cases, how- ever, it appears that erosion had occurred slowly. In the therapy of fistulas due to duodenal ulcer, various surgical procedures have been employed which have provided either excision of the fistula or  establishment of an environment in which closure would occur spontaneously. In the present case a large abscess in the right upper quadrant which communicated with the fistula was drained, and the fistula closed almost im- mediately. In  three reported cases simple excision of the fistula was done, with good results (Table 1).  In two cases excision of the fistula was combined with colectomy. I n  three cases a gastrojejunostomy was performed as primary therapy or  as an n(ljuva~it to clost~rc of tlic Two of thrsr tlircc patients tlcmo~istratctl the activity of tlieir ulcer diathesi5 hy tlie for- ~itntion of nlnrginal ulcers in the early post- operative period. 'rlic state of nutrition in this group of ~~nt i rn ts  \vas so poor that it is surprising that fecal tli\,crsinn has not bee11 lised to iliiprovc the tiletabolic stntc before attcmpt- i~ ig  n clcfinitive attack oil the fistula, as dcscribetl by Pfeitier '' and modifietl by TAiIie!. a t ~ l  Rlarsl~all.~ This was not done in an!. case reviewed iu this report. Orily five docuniet~tccl cases of duotleno- colic fistula secondaq- to gallbladtler disease have hccn rcportcd (Table 2).  That this ligure may be falsely low is suggested by the report of Judd and in which 4 duodenocolic fistulas were tabulated among 153 cases of cholecystenteric fistulas. In the cases reviewed here, the primary diagnosis of cholecystitis was either estab- lished in tlie past or entertained preopera- tively. In all cases brought to surgery the ! duodenocolic fistula was closed, and in all but one instance cholecystectomy was car- ried out. The treatment of the cases associated with ulcerative colitis was total colectomy and closure of the duodenal defect (Table i 3 ) .  In the cases secondary to appendicitis the excision of the fistula was combined with appentlectomy or right colectomy. All other cases (typhoid ulcer, foreign body, , tuberculous lynph nodes, postoperative fis- 1 tula, and unknown cause) were treated by simple excision of the fistula, with a good result (Table 4). Obviously, it is worth considerable effort to establish the etiology before operation, since the surgical therapy will depend to a large extent on the underlying cause. In general, the information obtained with a careful history and physical examination, a gastrointestinal series, and barium enema will allow an accurate opinion about the causative disease. If the fistula is between an otherwise nonnal transverse colon and the firnt or second part of the duodenum, In planning therapy, the most important single consideration is to obtain closure of the fistula either by direct o r  by indirect attack in the simplest possible way. The nutritional state of this group of patients is extremely poor. With closure of the fis- tula their condition can be improved dra- matically. It  has been said (Ogilvie13) that there is no more grateful patient in surgical practice than the one .with a suc- cessfully closed tlumlenocolic fistula. ,,I. ,It ,  :I, ' ~ ~ / ? ~ ~ / / / I ' l ~ . S  01.' s i ' / T ' ( ; / : / ~ ] .  ant1 tlicrc is 110 cvitlcrlce of ~alll)ln(l(lcr cl i s -  Summary I c ~ s e ,  the etiology will usually t l ~ l ~ l c n ~ l  ulcer. If the fistula is in this location, a11(1 there is rcflux of barium into the biiia? tree, or i f  thcre is othcr evitlcncc of thole- cystitis, thc etiology will usually bc gall- bladder clis~qsc. The fistulous openings in more unusual cascs, duc to other discascs, hnvc frequently been to other portions of the colon, or to thc third or  fourth portion of thc duotlenu~n. The eighth recorded case of benign duo- denocolic fistula due to duodenal ulcer is presented, and the clinical features, patho- genesis, and treatment of benign duodeno- colic fistulas from this and other causes are reviewed. 1 Irrespective of the etidlogy of the fistula, the patients present a common syndrome, which may include weight loss, emaciation, vomiting (often fecal), diarrhea, and a b  dominal pain and tenderness. The single most useful study in demon- strating the fistula has been barium enema. In establishing the etiologic factor respon- sible for the fistula, it is mandatory that a gastrointestinal series be obtained. An accurate preoperative diagnosis is necessary, since the surgical therapy will be influenced by this knowledge. In  almost all cases, direct closure of the fistula or  procedures designed to allow the fistula to close spontaneously have been successful. Jack.* Manorial Hospital, Mimi,  Fla (Dr. M e w ) .  VoL 78, Apvll, 19.99 1. I?ucaill Arclr. mnl. 2. Clayfnl ~ r ~ o d e n n r o l  3. llersllf ~ ) t !dcnornl  1951. 4. l t l f l~ i .  fiiliary 1 ; i k I  .j. Krwk,  6. I-ahcy, S r l r g i ~ d  lf plicatecl Pr  & Okt .  76 7. h v e l l ,  South. S u r ~  8. Marin: F. : Cmtri coliche bm 1953. 9. hlcCli~ Colonic Fic 10. McPl Fistula, wit 1940. 11. ?j,h Duodcnocol 1032, 1956. I ~ I I I < ~ ~  (]is- ~llllxlcll;,l ..]tic)li, a11,l l>iliar?. of choir- he gall- f'tii~igs ill diseases,  lr t ions of '11 portio11 '111portant losurc  of indirect  ". The , pat ients  ,i t h e  fis- +ved dra- jgilvie ' 8 )  gntient i n  ' h  a suc- I. llKI1 duo- ulcer  is i. patho-  ~ l u m l e n o -  ~ s e s  a r e  fiztu!n. ,.nclrome. ~nci :~t ion,  :trltl ab- . clenlon- I enema.  respon-  ory t ha t  I .  llosis i s  ~ p y  will REFERENCES 1. Rr~zaillc, hi. : Les Fistltlcs d~~tlrlino-cnliques, \rcl i .  rnnl. npp. ~ligest. 4.1 :(A{. 19.52. 2. Clayton. R. S., ant1 Tl~orilto~i. \\'. L. : Renign r)l~nleric*.olic Fisttrla, Ratlioloyy M :8.!2. 1953. ' 3, ~ ~ C ~ S ~ I C I ~ F O I I ,  L. hf.. x11d Kirs11cr. 1. n. : [)~~mlcnocolic Fistula, G n s t r ~ n t e r o l o ~ y  I 9 : W ,  10.: I. 4. Irrdtl. E. S., and Burden, 1.. C,. : I~rternal nilinry I'icti~ln. Ann. Sr1r.r. 81 :305, 1925. f 5 .  K r c k .  F.. in discussiol~ on Ogilvie." 6 .  1-alley. F. I-I., and hfarshall. S. F.: The Stlrrical J1;uiagement of Sonle of the More Cmi- I~licatnl Problems of Peptic ITlcer. Surp. Gynec. pi Ol)ct. 76:M1, 1943. i. I,ovell, D. 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Pfeiffer, D. n. : Vallle of i'rc.liinir~nry Cnlostonly in t l~c  Correction of Gnstrojejtr~~c~olic Fistltla, Ann. S i~ rp .  110: 659, 1039. 16. Plattner. H. C.. ant1 Cmlclscl~la~. E1.: Fistille duotleno-colique &nigne avec myorartlose dyspro- tCinin~ique, Rev. med. Suisse Kom. 76:792, 1956. 17. Railton, S. V.: Renifi DouclerirrColic Fistula, Canztd. M. A. J. 59:267. 1948. 18. Ransotn, H. I(., in discussion on  R i few 19. Rees, C. E.: Duatenocolic Fistula with Incompetent Sphincter of (hldi, J. A. M. A. 100:496, 1933. 20. Rife, C. S. : Benign Duodenocolic Fistula, A. M. A. Arch. Surg. 62:876, 1951. 21. Rosenqvist, H., and Sjoberg, S .  G.: Duodeno-Colic Fistulas, Acta chir. scandinav. 109 :293, 1955. 22. Winfield, J. M., in discussion on Rifc* , of t h e  ilow the ;.e been ,la. (Dr, I I 

Benign Duodenocolic Fistula

THOMAS E. STARZL

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Archives of Surgery

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Benign Duodenocolic Fistula

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