Grand Rounds Vol 8 pages 10–13

Speciality: Breast Surgery, gastroenterology;

General Surgery

Article Type: Case Report

DOI: 10.1102/1470-5206.2008.0004

Gastrocutaneous fistula: case report

and literature review

Alex Hotouras, Adhip Mandal, Veera Karri and Aarti Varma

United Lincolnshire Hospitals NHS Trust, Lincolnshire, UK

Corresponding address: Dr Alex Hotouras, Department of General Surgery,

Grantham and District Hospital, Grantham, Lincs, UK.

E-mail: alex007@doctors.org.uk

Date accepted for publication 21 January 2008

Abstract

We report the case of a 91-year-old lady who presented with a gastrocutaneous fistula in the

absence of any recent surgery. We review the literature and discuss this uncommon surgical

problem.

Keywords

Gastrocutaneous fistula; gastric ulcer.

Case report

A 91-year-old lady presented with a 2-week history of pain over the left anterior chest

wall. She described ‘‘foul-smelling’’ nipple discharge which was not blood-stained. She

was treated by her GP with antibiotics but the pain gradually worsened and she was now

describing a ‘‘whistling’’ noise when discharging. Her past medical history included a gastric

ulcer and a left mastectomy carried out 30 years ago for carcinoma of the breast. She did report

having problems with the healing of the mastectomy scar but a biopsy done 3 years previously

was clear.

On examination, there was significant erythema around the left anterior chest wall with

pus discharging from a small hole measuring 0.5mm�0.5mm (Fig. 1). Her chest radiograph

(Fig. 2) revealed shadowing in the left subchondral space but the lung fields were clear.

A provisional diagnosis of chest wall abscess was made and she was started on intravenous

antibiotics. On the following day undigested food was discharged from the left anterior chest wall

(Fig. 3). An oesophageal/gastrocutaneous fistula was suspected and she underwent a computed

tomography (CT) scan with contrast of her chest and abdomen (Fig. 4).

The CT scan demonstrated a soft tissue abnormality along the left anterior chest wall

communicating with the underlying greater curvature of the stomach. The findings were

consistent with suspected chest wall abscess communicating with the stomach. She also

underwent gastroscopy which demonstrated an ulcer associated with a fistula approximately

1 cm in diameter. Multiple biopsies were sent for histopathological examination which did not

reveal any evidence of malignancy. She eventually underwent excision of the ulcer and the fistula

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and the defect was repaired with a myocutaneous flap. Histological examination of the

excised specimen confirmed the presence of active chronic inflammation of the gastric

mucosa but there was no evidence of Helicobacter pylori infection, dysplasia or neoplasia.

Section of the skin showed extensive necrotic ulceration and the dermis displayed elastotic

degeneration and active chronic inflammation and fibrosis. The adipose tissue also revealed

focal fat necrosis.

Her post-operative recovery was uneventful and a gastrograffin swallow did not reveal any

abnormalities. The patient was reviewed in the outpatient clinic after 2 months and she was

eventually discharged from follow up. The full diagnosis was gastrocutaneous fistula associated

with benign gastric ulcer.

Fig. 1. Left anterior chest wall cellulitis and a small defect can be seen.

Fig. 2. Chest radiograph demonstrating left subchondral shadowing.

Gastrocutaneous fistula 11

Discussion

A fistula is a well documented but infrequent surgical complication that requires prompt

diagnosis as it can increase patient morbidity and mortality[1]. Reviews of gastrointestinal fistulae

have shown that pure gastrocutaneous fistulae are uncommon with an incidence ranging

between 2% and 20%[2]. The vast 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[2,3].

Gastrocutaneous fistulae may also be seen after removal of long standing gastrectomy

tubes, especially in the paediatric population[4]. 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 (e.g. silk suture which should be avoided when constructing a

gastrostomy), or associated chronic granulomatous disease such as Crohn’s[4,5]. The presence of

Fig. 4. Computerised tomography showing communication between the stomach and anterior chest wall.

Fig. 3. Undigested food material discharged via a gastrocutaneous fistula.

12 A. Hotouras et al.

a gastrostomy tube for more than 9 months is associated with a 45% incidence of gastrocutaneous

fistula[5].

In our case, there was no history of recent surgery so the most likely cause of the fistula

appears to be her benign gastric ulcer causing chronic inflammation and tissue erosion. This is a

rare presentation and, we believe, has been reported in the literature only once previously[2].

The aetiology of gastric fistulae is not well understood. Ischaemic gastric necrosis has been

postulated as playing an important role in the development of gastrocutaneous fistulae but it has

never been conclusively proven in the clinical setting[2]. In the case reported here, histopatho-

logical examination showed chronic inflammation of the gastric mucosa and necrosis of the skin

and subcutaneous fat so devascularisation secondary to chronic inflammation appears to be

implicated in the pathogenesis of a fistula.

The initial management of a gastrocutaneous fistula aims to increase gastric emptying

(e.g. metochlopramide), increase gastric pH (e.g. lansoprazole) and decrease intragastric

pressure[4,6]. Kobak and colleagues reported a 53% fistula closure rate following tract

cauterisation with silver nitrate and use of H2 antagonist[4]. Deruyter et al. reported two

successful cases of fistula closure with omeprazole and total parenteral nutrition[7].

Pearlstein and colleagues reported spontaneous closure of gastrocutaneous fistulae in 70% of

patients with conservative measures[2]. More recently, other researchers reported fistula closure

with minimally invasive procedures such as the application of endoclips, fibrin glue or collagen

plugs[6,8,9]. In addition, Makris and Sheiman reported fistula closure using a three-step technique:

(1) cauterisation of the fistula with silver nitrate to denude the tract of its epithelial lining;

(2) mechanical obliteration with Gelfoam pledgets; and (3) tract sclerosis using betadine[10].

Invariably, there will be a certain number of gastrocutaneous fistulae refractive to medical

management or minimally invasive procedures. In those cases, surgical excision is indicated[2,6].

Teaching point

In the absence of malignant disease or gastric outlet obstruction, gastrocutaneous fistulae should

be managed non-operatively. Spontaneous closure can be anticipated for the majority of cases

within a few weeks. Surgical excision should be reserved for gastrocutaneous fistulae intractable

to other forms of therapy.

References

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imaging evaluation. Radiology 2002; 224:9–23.

2. Pearlstein L, Jones C, Polk H. Gastrocutaneous fistula: etiology and treatment. Ann Surg 1978;

187:223–226.

3. Bryk D, Petigrow N. Post -splenectomy gastric perforation. Surgery 1967; 61: 239.

4. Kobak GE, McClenathan DT, Schurman SJ. Complications of removing percutaneous

endoscopic gastrostomy tubes in children. J Pediatr Gastroenterol Nutr 2000; 30:404–7.

5. Gordon JM, Langer JC. Gastrocutaneous fistula in children after removal of gastrostomy tube:

incidence and predictive factors. J Pediatr Surg 1999; 34:1345–6.

6. Siddiqui A, Kowalski T, Cohen S. Closure of a non healing gastrocutaneous fistula using an

endoscopic clip. South Med J 2007; 100:75–76.

7. Deruyter L, Van Blerk M, Cadiere GB, et al. Treatment of high-output gastric fistulas with

omeprazole. Hepatogastroenterology 1991; 38:83–86.

8. Lomis NN, Miller FJ, Loftus TJ, et al. Refractory abdominal-cutaneous fistulas or leaks:

percutaneous management with a collagen plug. J Am Coll Surg 2000; 190:588–92.

9. Gonzalez-Ojeda A, Avalos-Gonzalez J, Mucino-Hernandez MI, et al. Fibrin glue as adjuvant

treatment for gastrocutaneous fistula after gastrostomy tube removal. Endoscopy 2004;

36:337–341.

10. Makris J, Sheiman RG. Percutaneous treatment of a gastrocutaneous fistula after gastrostomy

tube removal. J Vasc Interv Radiol 2002; 13:205–7.

Gastrocutaneous fistula 13