|Year : 2014 | Volume
| Issue : 1 | Page : 60-62
Spontaneous gastrocutaneous fistula
Subramanian Kaushik, BS Madhu, Shashi H.B. Kumar
Department of General Surgery, Mysore Medical College and Research Institute, Mysore, Karnataka, India
|Date of Web Publication
C-123, Bhadra Nilaya, Amaravati Housing Colony, Harihar, Davangere, Karnataka - 577 601
Source of Support: None, Conflict of Interest: None
Gastrocutaneous fistula is an infrequent but a serious surgical complication confronting the surgeon. Isolated and spontaneous gastrocutaneous fistula is an entity which has received scant attention in the surgical literature. Herein, we report a 68-year-old patient who came to the surgical outpatient with a history of recurrent abdominal pain for 1 year and discharge from just above the umbilicus for 3 days. He had no past history of abdominal surgeries. There were no comorbid conditions afflicting him. On examination, there was a stoma above the umbilicus with surrounding hyperemia of the skin. Bile-tinged fluid noted discharging from the external opening. Abdominal contrast-enhanced computed tomography (CECT) showed a fistulous tract from the skin surface to the anterior surface of the stomach with extravasation of contrast into rectovesical pouch. Upper gastrointestinal endoscopy showed Grade 3 esophageal candidiasis. Clinical diagnosis of gastrocutaneous fistula was made. Laparotomy revealed a gastrocutaneous fistula from the anterior wall of the stomach to the anterior abdominal wall. The fistula was excised and the gastric defect closed. Edges of the gastric perforation were biopsied and a feeding jejunostomy was placed. The patient succumbed to acute respiratory distress syndrome (ARDS) in the postoperative period. Histopathological examination revealed normal gastric mucosal lining with fibrosis and chronic inflammation in the submucosa with no evidence of malignancy. The most likely cause for such a fistula appears to be a benign gastric ulcer causing chronic inflammation and erosion, which is a rare entity and must be borne in mind in elderly patients presenting with gastric ulceration.
Keywords: Gastric cancer, gastric ulcer, gastrocutaneous fistula, spontaneous
|How to cite this article:
Kaushik S, Madhu B S, Kumar SH. Spontaneous gastrocutaneous fistula. Arch Int Surg 2014;4:60-2
A gastrocutaneous fistula (GCF) represents a fistula connecting the stomach and the skin. By definition, it consists of an internal orifice (gastric outlet), an external orifice (cutaneous outlet), and a tract (usually covered by epithelium). In the absence of malignancy, radiation exposure, or iatrogenic instrumentation of the gastrointestinal tract, the occurrence of external gastric fistulae is relatively rare. Only two cases have been reported in the literature. , The objective of this paper is to highlight the important role of timely upper gastrointestinal endoscopy in diagnosing a peptic ulcer disease and initiating the appropriate treatment. This case also highlights one of the rare complications of peptic ulcer disease.
| Case Report
A 68-year-old patient presented to the surgical outpatient with complaints of epigastric pain for 1 year and a discharging stoma from just above the umbilicus for 3 days. The patient did not have any comorbid diseases. He had undergone partial amputation of the penis for carcinoma about 5 years back but did not receive radiation or chemotherapy. He smoked cigarette for the past 30 years. He was not an alcoholic and not a known patient of peptic ulcer disease. Physical examination revealed a dehydrated patient with pallor. On abdominal examination, a stoma was observed just above the umbilicus in the midline measuring about 0.5 × 1 cm [Figure 1]. Bile-stained fluid was discharging from the opening. Surrounding skin was hyperemic. No masses were palpable in the abdomen. A clinical diagnosis of GCF was made. On admission, undigested food particles and recently ingested liquids were observed to come out of the external opening, thus confirming a diagnosis of GCF. Rest of the systems were normal on examination.
Hemoglobin was low at 8.0 g%. There was hypokalemia of 2.9 m Eq. Urea and other electrolytes were normal. Abdominal ultrasound was unremarkable. CECT of abdomen revealed a fistulous tract from the skin to the anterior wall of the stomach with minimal extravasation of the contrast and collection in the rectovesical pouch. Inflammatory changes in the anterior abdominal wall were noted. No pre- or para-aortic lymphadenopathy, hepatomegaly, or evidence of space occupying lesion in the abdominal cavity was observed. Esophagogastroduodenoscopy revealed Grade 3 esophageal candidiasis, and the procedure was aborted prior to visualization of the stomach due to severe inflammation. Screening for human immunodeficiency virus (HIV) infection was negative. Culture and sensitivity of the discharge came negative for pathogens.
A stoma bag was placed to collect and measure the effluent which was persistently less than 200 ml/day. Conservative management was initiated. Stomach was decompressed by continuous nasogastric tube suctioning. Rabeprazole 20 mg was administered intravenously twice a day and metoclopramide 10 mg was given intramuscularlyevery 6 hours as a part of the treatment regimen along with simultaneous correction of the electrolyte imbalances and anemia. Regular wound dressing with surrounding skin care was done.
After 3 weeks of admission, with no signs of improvement, the patient was scheduled for laparotomy under regional anesthesia. Findings at laparotomy include a fistulous tract extending from the anterior abdominal wall to the anterior surface of the body of the stomach [Figure 2]. Dense omental plugging around the fistulous tract was noticed and subsequently released.
The tract was excised completely with a rim of gastric tissue and sent for histopathological examination. The perforation in the stomach was closed primarily with nonabsorbable sutures [Figure 3]. A feeding jejunostomy was placed and secured. Postoperatively, the patient developed respiratory distress and was taken to the ICU. He succumbed to ARDS on the 4 th postoperative day. Histopathological examination revealed gastric mucosal ulceration with plenty of chronic inflammatory cells and fibrosis [Figure 4]. No evidence of malignancy was noted.
Reviews of gastrointestinal fistulae have shown that pure GCF are uncommon with an incidence ranging between 2% and 20%.  The majority usually involve the greater curvature of the gastric fundus following surgery. In particular, they are most likely to arise from leakage of gastroduodenal or gastrojejunal anastomosis after gastrectomy or following splenectomy. , GCF may also be seen after removal of long standing gastrostomy tubes, especially in the paediatric population.  The defect does not close spontaneously if the gastrostomy has been used for a long time if there is delayed gastric emptying, obstruction, foreign body, or associated chronic granulomatous disease such as Crohn's. , The presence of a gastrostomy tube for more than 9 months is associated with a 45% incidence of GCF. 
Perforations that occur in the gastrointestinal tract can be closed by means of commercially available endoscopic clips deployed through the working channel of the endoscopes. In addition, other endoscopic techniques have been proposed such as endoscopic stenting, endoscopic gluing with fibrin and Histoacryl or Vicryl plugs. Several types of clipping devices are available such as rotatable devices, single-shot systems, and devices that can be reopened. Also available is an over-the-scope clip (OTSC) to seal such perforations. 
In our patient, this method of treatment could not be tried for lack of expertise.
In our case, there was no history of recent surgery; so, the most likely cause of the fistula appears to be a benign gastric ulcer causing chronic inflammation and tissue erosion. This is a rare presentation. The etiology of gastric fistulae is not well understood. Ischemic gastric necrosis has been postulated as playing an important role in the development of GCF, but it has never been conclusively proven in the clinical setting.  Histopathological examination in our patient showed chronic inflammation of the gastric mucosa and necrosis of the skin and subcutaneous fat; so, devascularization secondary to chronic inflammation appears to be implicated in the pathogenesis of the fistula.
As our patient did not have any previous abdominal surgeries or radiation, the most likely cause for such a fistula appears to be a benign gastric ulcer causing chronic inflammation and erosion, which is a rare entity and must be borne in mind in elderly patients presenting with gastric ulceration.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]