Gastrocolocutaneous Fistula: An Unusual Case of Gastrostomy Tube Malfunction with Diarrhea

Abstract

A gastrocolocutaneous fistula is a rare complication of percutaneous endoscopic gastrostomy (PEG). We report a case of a gastrocolocutaneous fistula presenting with intractable diarrhea and gastrostomy tube malfunction. A 62-year-old woman with a history of multiple system atrophy was referred to us because of PEG tube malfunction. Twenty days prior to presentation, the patient started developing sudden diarrhea within minutes after starting PEG feeding. Fluoroscopy revealed that the balloon of the PEG tube was located in the lumen of the transverse colon with the contrast material filling the colon. Subsequently, the PEG tube was removed and the opening of the gastric site was endoscopically closed using hemoclips. Clinicians should be aware of gastrocolocutaneous fistula as one of the complications of PEG insertion. Sudden onset of diarrhea, immediately after PEG feedings, might suggest this complication, which can be effectively treated with endoscopic closure.

Full text

Copyright © 2017 Korean Society of Gastrointestinal Endoscopy 1
CASE REPORT
2017 Aug 31. [Epub ahead of print]
https://doi.org/10.5946/ce.2017.062
Print ISSN 2234-2400 • On-line ISSN 2234-2443
Gastrocolocutaneous Fistula: An Unusual Case of Gastrostomy Tube
Malfunction with Diarrhea
Junghwan Lee1, Jinyoung Kim1, Ha il Kim1, Chung Ryul Oh1, Sungim Choi1, Soomin Noh1, Hee Kyong Na2 and Hwoon-Yong Jung2
1Department of Internal Medicine, 2Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine,
Asan Medical Center, Seoul, Korea
A gastrocolocutaneous fistula is a rare complication of percutaneous endoscopic gastrostomy (PEG). We report a case of a
gastrocolocutaneous fistula presenting with intractable diarrhea and gastrostomy tube malfunction. A 62-year-old woman with a
history of multiple system atrophy was referred to us because of PEG tube malfunction. Twenty days prior to presentation, the patient
started developing sudden diarrhea within minutes aer starting PEG feeding. Fluoroscopy revealed that the balloon of the PEG tube
was located in the lumen of the transverse colon with the contrast material lling the colon. Subsequently, the PEG tube was removed
and the opening of the gastric site was endoscopically closed using hemoclips. Clinicians should be aware of gastrocolocutaneous
stula as one of the complications of PEG insertion. Sudden onset of diarrhea, immediately aer PEG feedings, might suggest this
complication, which can be eectively treated with endoscopic closure. Clin Clin Endosc 2017 Aug 31. [Epub ahead of print]
Key Words: Gastrostomy; Complications; Fistula
Open Access
INTRODUCTION
Percutaneous endoscopic gastrostomy (PEG) is a safe and
effective method for providing long-term enteral nutrition.
However, previous studies have reported possible complica-
tions such as wound infection, tube dislodgement, peristomal
leakage, bleeding, internal organ injury, necrotizing fasciitis,
and aspiration pneumonia.1 Most complications are minor,
but some rare severe complications may be life threatening.2
Gastrocolocutaneous fistula is a rare complication of PEG
tube placement, with an incidence rate of 0.5%–3%.3 This
complication develops from the perforation of the interposed
colon when a PEG tube is placed into the stomach. Aected
patients usually remain asymptomatic for a few days to sev-
eral months. erefore, gastrocolocutaneous stula is usually
unrecognized until the tube is replaced or until typical symp-
toms develop.4 We report a case of a gastrocolocutaneous
fistula that presented with diarrhea and gastrostomy tube
malfunction.
CASE REPORT
A 62-year-old woman with a medical history of multiple
system atrophy was admitted to our institution owing to gas-
trostomy tube malfunction that seemed to manifest during
the day time. e patient had undergone uneventful PEG four
months ago and had been fed without diculty via the PEG
tube. However, twenty days prior to presentation, the patient
had begun to develop sudden diarrhea within minutes aer
starting PEG feedings. She had been treated with antidiar-
rheal medication, but it had proven ineective. Subsequently,
the PEG tube was clogged, and the patient was referred to the
emergency department.
e patient was hemodynamically stable, and physical ex-
Received: April 25, 2017 Revised: July 20, 2017
Accepted: July 21, 2017
Correspon dence: Hee Kyong Na
Division of Gastroenterolog y, Department of Internal Medicine, University of
Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Song-
pa-gu, Seoul 05505, Korea
Tel: +82-2-3010-5676, Fax: +82-2-2045-4043, E-mail: hkna77@naver.com
cc This is an Open Access article distributed under the terms of the Creative
Commons Attr ibution Non-Commercial License (http://creat ivecommons.org/
licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution,
and reproduction in any medium, provided the original work is properly cited.

2
amination revealed a so and at abdomen with normal bow-
el sounds. Laboratory ndings were all within normal limits.
A radiologic study with gastrografin, administered through
the PEG tube, showed the balloon of the PEG tube in the lu-
men of the transverse colon with the contrast material lling
the transverse colon (Fig. 1). e PEG tube was immediately
removed, and the gastric side opening was endoscopically
closed using argon plasma coagulation and hemoclips (Fig. 2).
Computed tomography (CT) of the abdomen and pelvis
showed a linear tract anterior to the transverse colon, with
the stomach located behind the transverse colon (Fig. 3).
No pneumoperitoneum, abnormal fluid collections, or peri-
tonitis was observed. One week after removal of the PEG
tube, esophagogastroduodenoscopy (EGD) was performed.
Fluoroscopy revealed that no contrast material had entered
the colon or the peritoneal space when the contrast was shot
through the EGD biopsy channel towards the previous gas-
trostomy site (Fig. 4). Follow-up CT scan showed obliteration
of the previous stulous tract, and enteral feeding was initiat-
ed via a nasojejunal feeding tube. Because the patient and her
family refused to undergo additional PEG procedure, surgical
gastrostomy was scheduled and the patient was sent back to a
rehabilitation hospital.
DISCUSSION
Gastrocolocutaneous stula is a rare complication of PEG,
which occurs when a PEG tube penetrates the interposed
colon between the abdominal wall and the stomach during
the initial insertion of PEG.5 Adhesion from the previous lap-
arotomy has been suggested as one of the major risk factors
Fig. 1. (A, B) Contrast radiography with gastrogran showing the balloon of the percutaneous endoscopic gastrostomy tube in the lumen of the transverse colon with
contrast lling in the transverse colon.
A B
Fig. 2. Endoscopic ndings. (A) The gastric side of the stula opening is shown at the anterior side of the body (B) Argon plasma coagulation was applied to the s-
tula opening. (C) Hemoclips were applied to close the stula opening.
A B C

3
Lee JH et al. A Case of Gastrocolocutaneous Fistula
for gastrocolocutaneous fistula; however, a previous review
reported that only 8 of the 28 patients with gastrocolocutane-
ous stula had undergone previous abdominal surgery.6,7 Sim-
ilarly, our patient did not have a history of abdominal surgery.
Gastroenterologists should consider the possibility of colonic
interposition between the abdominal wall and the stomach
during insertion of PEG tube, even in patients without a
history of abdominal surgery. High-riding transverse colon,
abnormal posture and spinal deformity, and over-distended
stomach during EGD may contribute to the development of
gastrocolocutaneous stula.7-9
Although a gastrocolocutaneous fistula may form at the
time of insertion of the PEG tube, symptoms may not mani-
fest until the PEG tube migrates into the transverse colon or
until the tube is replaced.10 For patients who do not undergo
tube replacement, an asymptomatic period may persist up to
several months aer the initial PEG tube placement.7 When
the tube lodges in the transverse colon, patients present typical
symptoms, such as sudden onset of diarrhea, within minutes
after starting PEG tube feeding, and passage of undigested
feeding formula.11 Appearance of fecal material in the PEG
tube or feculent vomiting may also be a result of the retro-
grade passage of fecal material from the colon via the stula.12
In our case, the typical symptoms manifested approximately 3
months aer PEG procedure, and gastrocolocutaneous stula
was diagnosed when the patient was referred to our center
owing to gastrostomy tube malfunction.
Several techniques have been suggested to minimize the
risk of colon penetration. Strodel et al. suggested identifying
the interposing colon between the abdominal wall and the
stomach by aspirating a saline-lled syringe to detect air bub-
bles that appear before the endoscopic visualization of the
needle in the gastric lumen.13 Excessive inflation of air into
the stomach during PEG procedure makes the transverse co-
lon interpose between the abdominal wall and the stomach;
therefore, excessive ination of air into the stomach should be
avoided during the procedure.6 e use of ultrasound or CT
scan can be considered in patients with complex abdominal
anatomy. Techniques such as trans-illumination and finger
pressure help guide the placement of the puncture site.
When gastrocolocutaneous fistula formation is suspected,
upper endoscopy is recommended. Radiologic study with a
water-soluble contrast medium or abdominal CT scan may
help conrm the diagnosis.11 Colonic haustra and gastrostomy
tract can be visualized through uoroscopic images and CT
scan, as in our case.
Data in the previous reports are insufficient to propose
standard management for gastrocolocutaneous fistula. In
most cases, treatment for gastrocolocutaneous fistula aims
to allow spontaneous closure of the fistula by removing the
feeding tube.4,7,9,14 A laparotomy is recommended only if there
is an evidence of peritonitis.7,15,16 Previously reported cases in
which gastrocolocutaneous stula was conservatively treated
are summarized in Table 1.
There have been attempts at endoscopic treatment of fis-
tulae aer removal of PEG tube (Table 2).4,9,17-20 Hwang et al.
suggested that endoscopic treatments would be helpful in cas-
es where the stula does not spontaneously close within sev-
eral days.17 Kim et al. suggested that endoscopic closure would
accelerate the blockage of the stula in patients with a risk of
delayed wound healing and infection (e.g., diabetes mellitus).18
We assume that endoscopic closure of gastrocolocutaneous
stula can be performed in patients with a large stula open-
Fig. 4. One week after removal of percutaneous endoscopic gastrostomy
tube, contrast radiography showing no evidence of gastric leakage.
Fig. 3. Contrast-enhanced abdominal computed tomography revealing the
gastrostomy tract in the left anterior abdominal wall anterior to the transverse
colon.

4
ing that cannot be spontaneously closed. Even if the stulous
opening is small, endoscopic management would accelerate
the blockage of stula, leading to earlier oral feeding.
The majority of previous endoscopic interventions were
conducted via colonoscopy by clipping the colonic side of the
fistula opening. However, we performed endoscopic closure
Table 1. Conservatively Treated Cases of Gastrocolocutaneous Fistula after PEG
Study Age/Sex Presentation Underlying disease Onset of symptoms from
PEG insertion Treatment
Kim et al. (2014)477/M Loosening of PEG tube Dementia 33 mo Removal of PEG
tube
F riedmann et al.
(2007)7
84/F Fecal materials in PEG tube Dementia 5 wk aer tube exchange
68/M Fecal materials in PEG tube Hemorrhagic stroke 2 wk
73/M Diarrhea Dementia 14 mo
75/M Fecal materials in PEG tube Aer surgery 2 wk
83/M Fecal materials in PEG tube Parkinson’s disease 1 yr aer 2nd tube
exchange
Lee et al. (2014)965/M Fecal materials in PEG tube Cerebellar infarction 6 mo aer tube exchange
Liu et al. (2010)14 87/M Diarrhea Dementia 1 mo
PEG, percutaneous endoscopic gastrostomy.
Table 2. Endoscopic or Surgical Treatment for Patients with Gastrocolocutaneous Fistula after PEG
Study Age/Sex Presentation Underlying
disease
Onset of
symptoms from
PEG insertion
Treatment
(Endoscopic
or surgical)
Detailed method of
treatment
Kim et al.
(2014)4
74/M Diarrhea Cerebral
infarction
9 mo Endoscopic
treatment
Removal of PEG tube and clipping
at the colonic side of the stula
Lee et al.
(2014)9
47/M Fecal materials in
PEG tube
Traumatic
subdural
hematoma
12 mo Endoscopic
treatment
Removal of PEG tube and clipping
at the colonic side of the stula
Hwang et al.
(2012)17
72/F Fecal materials in
PEG tube
Medullary
infarction
3 days Endoscopic
treatment
Removal of PEG tube and clipping
at the colonic side of the stula,
followed by gastric side clipping
and application of detachable snare
Kim et al.
(2002)18
53/M Diarrhea and
feculent vomiting
Hypoxic brain
damage, diabetes
mellitus
2 wk Endoscopic
treatment
Removal of PEG tube and clipping
at the colonic side of the stula
Melmed et al.
(2009)19
82/M Feculent vomiting Not available 12 mo Endoscopic
treatment
Removal of PEG tube and clipping at
the gastric side of the stula failed.
Cardiac septal defect closure device
was applied.
Bertolini et al.
(2014)20
85/M Diarrhea Larynx cancer 10 mo Endoscopic
treatment
Removal of PEG tube and closure
of the colonic orice of the stula
with over-the-scope-clip
Friedmann et
al. (2007)7
67/M Severe hunger and
diarrhea
Schizophrenia,
recurrent bowel
obstruction
1 mo Surgical
treatment
Elective surgical gastrostomy
Huang et al.
(2005)15
44/M Diarrhea Tonsil cancer 2.5 mo Surgical
treatment
Elective surgical gastrostomy
Okutani et al.
(2008)16
27/M Diarrhea Cerebral palsy A few months Surgical
treatment
Surgical gastrostomy and stula
excision
PEG, percutaneous endoscopic gastrostomy.

5
Lee JH et al. A Case of Gastrocolocutaneous Fistula
on the gastric side opening, because leakage of gastric juice
through the fistula can disturb the spontaneous closure of
the stula. e method of endoscopic treatment is likely de-
termined according to the size of the fistula opening. Small
stula tracts were treated only with hemoclips, but detachable
snare with clips, over-the-scope clip, and cardiac septal de-
fect closure device have been used for relatively large stula
openings.4,9,17-20 In our case, we used hemoclips to close the
stula, and argon plasma coagulation was performed before
clipping to help mucosal adhesion. From our experience, and
as observed in previously reported cases, whether endoscopic
treatment entails closure of the gastric or colonic side depends
on the case. Herein, we report a case in which the patient was
treated by clipping the gastric side of the fistulous opening
alone, while the patients in the majority of previous cases were
treated by clipping the colonic side of the fistulous opening
with or without the gastric side opening.
In conclusion, PEG-associated complications are expected
to increase along with the increasing requirement for PEG.
Clinicians should be aware of the typical symptoms of gastro-
colocutaneous stula in order to establish an early diagnosis
and to provide proper treatment for the complications. Endo-
scopic closure can be an eective method for the treatment of
a gastrocolocutaneous stula.
Conflicts of Interest
e authors have no nancial conicts of interest.
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