University of Missouri Columbia, MO, United States
Harleen K. Chela, MBBS, MD1, Mary Mikhael, MD1, Zachary D. Smith, MD2, Omer Basar, MD1, Deepthi Rao, MD, MS1, Veysel Tahan, MD1, Ebubekir Daglilar, MD1 1University of Missouri, Columbia, MO; 2University of Missouri Health System Columbia, Edmond, OK
Introduction: Colo-duodenal fistula is a unique entity and uncommonly encountered. We present a case of a malignant colo-duodenal fistula that likely originated from possible ectopic/heterotopic pancreatic tissue within the duodenal ampulla
Case Description/Methods: A 37-year-old male presented for acute worsening of chronic intermittent epigastric pain which was accompanied by 3-week history of vomiting feculent matter. He had been using nonsteroid anti-inflammatory drugs as analgesics for the previous year. Pertinent history included unintentional 20-pound weight loss over the previous month and no overt signs of gastrointestinal hemorrhage. On examination, his abdomen was tender to palpation in epigastric region without rebound or guarding. Laboratory panel showed microcytic anemia with hemoglobin of 4.8 g/dl. A CT scan of abdomen showed fistulous tract between transverse colon and second portion of duodenum with surrounding inflammation (Figure A). Upper endoscopy revealed large amount of liquid stool in the stomach. The duodenal sweep had a large ulcer with fistulous connection to the colon which was confirmed on advancing scope through fistula tract (Figures B & C). His colonoscopy revealed the site of the fistula which could not be traversed due to surrounding edema. Biopsies from the duodenal ulcer showed invasive adenocarcinoma arising from small bowel with desmoplastic stroma (Figure D) and negative for microsatellite instability. A Whipple procedure and right hemicolectomy performed, and surgical specimen showed invasive adenocarcinoma arising from duodenum and invading pancreas and peripancreatic tissues with fistulation into the colon. A mixed pancreatic ductal type and intestinal type differentiation was noted with minor component of pancreatic acinar differentiation (Figures E & F). Diagnosis of Stage IIIB/stage IV adenocarcinoma of the duodenum versus locally advanced stage IV adenocarcinoma of the pancreas was made and started on folfirinox then pembrolizumab.
Discussion: Malignant colo-duodenal fistula is a rare entity and scarcely reported in literature from colon cancer and rarely from duodenal adenocarcinoma. Histologically our case was thought to arise possibly from ectopic/heterotopic pancreatic tissue within the duodenal ampulla as there were mixed ductal and acinar type of pancreatic differentiation and intestinal differentiation. This pattern is scarcely described thus far. The typical management is extensive surgery with radical right hemicolectomy and pancreaticoduodenectomy.
Figure: Figure A: CT scan of abdomen showed fistulous tract between transverse colon and second portion of duodenum with surrounding inflammation.
Figures B & C: The duodenal sweep had a large ulcer with fistulous connection to the colon which was confirmed on advancing scope through fistula tract.
Figure D: Biopsies from the duodenal ulcer showed invasive adenocarcinoma arising from small bowel with desmoplastic stroma (Hematoxylin and Eosin staining, 100x magnification).
Figures E & F: A mixed pancreatic ductal type and intestinal type differentiation was noted with minor component of pancreatic acinar differentiation.
Disclosures: Harleen Chela indicated no relevant financial relationships. Mary Mikhael indicated no relevant financial relationships. Zachary Smith indicated no relevant financial relationships. Omer Basar indicated no relevant financial relationships. Deepthi Rao indicated no relevant financial relationships. Veysel Tahan indicated no relevant financial relationships. Ebubekir Daglilar indicated no relevant financial relationships.
Harleen K. Chela, MBBS, MD1, Mary Mikhael, MD1, Zachary D. Smith, MD2, Omer Basar, MD1, Deepthi Rao, MD, MS1, Veysel Tahan, MD1, Ebubekir Daglilar, MD1. P2271 - A Dirty Fecal Vomiting Sign: The Fate Secondary to Malignant Colo-Duodenal Fistula, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
