P0190 - Gastrocolic Fistula in a Patient With Post Bariatric Anatomy Who Initially Had Findings Concerning for Ischemic Colitis

Ray Lu, MD¹, Jennifer Behzadi, MD², Adeeti J. Chiplunker, MD^2
1The Ohio State University Wexner Medical Center, Westerville, OH; ²The Ohio State University Wexner Medical Center, Columbus, OH

Introduction: Fistulas and leaks are known complications post bariatric surgery. Gastrocolic fistulas are uncommon and more often caused by cancer. We present a rare case of gastrocolic fistula in a patient with post bariatric anatomy who initially had findings concerning for ischemic colitis.

Case Description/Methods: A 66-year-old man with history of remote Billroth I for peptic ulcer disease complicated by post-op leak converted to Roux-en-Y is admitted for respiratory failure. On hospital day 16, he developed melena and hemoglobin downtrended from 8.1 g/dl to 5.1 g/dl. His BP was noted to be 80s/50s and HR in the 120s. He responded to resuscitation. On day 18, EGD was performed with unremarkable findings including a healthy appearing gastro-jejunal anastomosis and intact staple line in the pouch. Jejuno-jejunal anastomosis was not reached. Post-EGD, patient continued to have melena and require blood transfusions but remained hemodynamically stable. Colonoscopy was pursued. Patient had difficulty tolerating colon prep and required NG tube. On day 22, colonoscopy showed a well-defined area in the ascending colon concerning for ischemic colitis with an ulcerated area that was felt to represent fistula versus clot. Biopsies were taken. Vascular surgery was consulted. CTA A/P did not show extravasation or mesenteric ischemia. On day 23, colonoscopy biopsy results came back with gastric oxyntic-type mucosa with acute inflammation and detached ulcer debris. CT A/P with PO contrast was performed which showed a 7.9 cm LUQ collection with communication to the distal transverse colon, and NG tube coursing through the gastric pouch staple line into the LUQ collection, which also had a questionable tract to the excluded stomach. General surgery was consulted. On day 29, IR was consulted for percutaneous drain placement and noted marked interval decrease in size of the collection, with only 50 cc of thick bloody fluid aspirated. On day 48, patient was discharged to LTACH, with plans for further surgical evaluation as an outpatient.

Discussion: It is important for gastroenterologists to have a thorough understanding of post-bariatric surgical anatomy. Extraluminal gastric leaks can result in abscess, and chronic gastro-gastric fistulas may be found in the presence of marginal ulcers. Gastro-colic fistulas are more rare and endoscopy is not known to be sensitive for diagnosis. However, this case also demonstrates how an abscess leading to gastro-colic fistula can have the appearance of ischemic colitis on colonoscopy.


Figure: I and II - Hepatic flexure: findings concerning for ischemic colitis with arrow pointing to area concerning for fistula vs clot.
III - CT A/P transverse view.
IV - CT A/P coronal view.
A - LUQ collection.
B - Remnant stomach.
C - Defect in transverse colon communicating with LUQ collection.
D - Gastric pouch.
E - NG coursing through esophagus.


Disclosures:
Ray Lu indicated no relevant financial relationships.
Jennifer Behzadi indicated no relevant financial relationships.
Adeeti Chiplunker: Takeda – Speaker's Bureau.


Ray Lu, MD¹, Jennifer Behzadi, MD², Adeeti J. Chiplunker, MD². P0190 - Gastrocolic Fistula in a Patient With Post Bariatric Anatomy Who Initially Had Findings Concerning for Ischemic Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.