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J Ped Surg Case Reports 3 (2015) 10e12

Journal of Pediatric Surgery CASE REPORTS

journal homepage: www.jpscasereports.com

Gastro colic fistula in a neonate e Case report of a rare complicationof necrotizing enterocolitisq

Shilpa Kalane*, Pradeep Suryawanshi, Umesh Vaidya, Shashank ShrotriyaDivision of Neonatology, Department of Pediatrics, Sahyadri Speciality Hospital, Nagar Road, Pune, Maharashtra, India

a r t i c l e i n f o

Article history:Received 19 September 2014Received in revised form2 November 2014Accepted 4 November 2014

Key words:Gastro colic fistulaNECNeonate

q This is an open access article under the CCcreativecommons.org/licenses/by-nc-nd/3.0/).* Corresponding author. Flat no. 202, G Building

Pune-46, Maharashtra, India. Tel.: þ91 9552024242 (mE-mail address: shilpauk1@gmail.com (S. Kalane).

2213-5766/$ e see front matter � 2015 The Authors.http://dx.doi.org/10.1016/j.epsc.2014.11.002

a b s t r a c t

Gastrocolic Fistula is, in the majority of cases the pathological communication between stomach andtransverse colon. It occurs mostly in adults, but they can be present in infants, as well, as a result ofcongenital abnormalities or iatrogenic procedures (i.e. migration of naso gastric tube that placed before).We report a case of 10 days old full term, male neonate, was on naso gastric tube feeds, had clinicalfeatures of necrotizing enterocolitis (NEC), diagnosed to have gastrocolic fistula on barium enema studyand confirmed on CT abdomen. Intraoperatively, baby had multiple perforations with gastrocolic fistula.Histopathological examination was suggestive of NEC. We searched literature, we could find seven casereports.

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1. Case report

A male neonate, born by full term emergency caesarian sectionto a primigravida mother for meconium stained amniotic fluid, waslimp at birth, had meconium aspiration syndrome and hence wasreferred to us for further management. Baby was small for gesta-tional age with weight was 1980 g, Head circumference 34 cm, andtotal length at birth was 49 cm. Baby was ventilated for 3 days formoderate meconium aspiration syndrome. Trophic feeds via nasogastric tube were initiated on day 1 of life, baby reached full feeds(180 ml/kg/day, expressed breast milk) on day 6 of life. Baby waslethargic and hypotonic on day 5 of life. CRP was positive, hemo-gram, CSF and electrolytes were normal. In view of sepsis, antibi-otics were started. On day 8 of life baby had increasing yellowishgreenish aspirates suggestive of feeding intolerance. X ray abdomenwas done was suggestive of dilated bowel loops, Necrotizingenterocolitis was suspected. Baby was kept NPO. In view of pro-gressively increasing aspirates, Barium enema study was done onday 10 of life showed gastro colic fistula (Fig. 1), was confirmed onCT scan abdomen (Fig. 2). On day 11, exploratory laparatomy was

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done. Baby had 5 intestinal perforations (Fig. 3) e intestinalresection and diversion was done.

Histopathological examination of intestinal biopsy specimenshowed mucosal edema, hemorrhage, necrosis suggestive of NEC.Baby was kept NPO for 5 days postoperative. On postoperative day6, feeds were started. On day 21 of life, baby was on exclusive breastfeeding, discharged on day 24 of life with discharge weight 1990 g.

2. Discussion

In children, gastro colic fistulae are very rare, especially innewborns and infants. Since 1945, only 8 cases have been reportedin the literature [1]. Gastro colic fistulae result from perforation ofthe stomach into the colon or of the opposite, mostly among pre-mature and immature small-for-dates infants [2]. This occursbecause of stress ulcer, gastric tissue ischemia or trauma, due tocomplications of necrotizing enterocolitis, Hirschsprung’s diseaseand meconium ileus, respectively. Also, gastro colic fistulae inchildren can occur after migration or placement of PEG feedingtubes [2].

Strictures complicating NEC occur in 20% of patients and usuallyinvolve colon [3]. In contrast fistula formation complicating NEC israre and may occur with or without stricture. Clinical data on ourone patient and the 8 previously described in literature are sum-marized in Table 1.

The plain film findings in the presence of fistula are nonspecific.Clinically our patient presented with increasing aspirates without

s reserved.

Fig. 1. Supine abdominal X ray with Barium enema study. (aed) X rays show dye slowly advancing from rectum, sigmoid (a), descending colon to stomach suggestive of gastro colicfistula (b) then to the rest of the intestine (c and d).

Fig. 2. CT scan abdomen suggestive of gastro colic fistula.

S. Kalane et al. / J Ped Surg Case Reports 3 (2015) 10e12 11

abdominal distention and previously reported cases presented withdiarrhea and abdominal distention. Clinical symptoms suggestive offeeding intolerance and nonspecific bowel gas pattern on plain x rayshould raise the possibility of an existing fistula. Several mechanismsmay be proposed for the development of enterocolic fistula followingNEC. Severe colonic ischemia and subsequent bowel necrosis maydevelop over time inciting an inflammatory response. Continuousinflammationmay result in adherence of affected segment of colon toadjacent bowel and eventual fistulization. Alternatively, a sub acuteperforation may be walled off by adjacent viscera resulting in fistulaformation. In cases mentioned in literature, time gap between diag-nosis of NEC and fistula formation was wide around 2 weekse10weeks. However in our case it was early. In this case baby was IUGR,had suffered asphyxia and had MAS. This may have aggravated in-testinal ischemia, leading to early postnatal fistula formation.Alternatively as mentioned earlier sub acute perforation may bewalled off by adjacent viscera resulting in fistula formation. Asmentioned in most of the reported cases, present case also did wellpostoperatively.

Gastro colic fistulae, a condition with poor prognosis, can arisefrom a variety of pathological processes, spontaneous or iatrogenic,and the classical symptoms are increasing aspirates, abdominaldistention, vomiting and diarrhea. The best diagnostic method is

Fig. 3. Small intestinal perforations (a-e) with gastro colic fistula.

Table 1Cases of enteric fistulas due to necrotizing enterocolitis.

Author Diagnosis of NEC (age) Diagnosis of fistula (age) Birth weight (g) Fistula location Colonic stricture Clinical presentation Follow up

Pein [4] 7 days 35 days ? Gastro colic No Vomiting, diarrhea Died post surgeryFiror [5] ? 28 days ? Gastro jejunocolic No Vomiting, diarrhea Died post surgeryBeck [6] 5 days 18 weeks 2610 Ileocolic Yes Distention, constipation Surgery, did wellKosloske [7] ? 18 weeks ? Enterocolic No ? Surgery, did wellPaley [8] 7 days 63 days 3800 Jejunocolic Yes Distention, vomiting Surgery, did wellKiely [9] 5 days 32 days 3600 Jejunoileocolic Yes Vomiting, diarrhea Surgery, did wellLevin [1] 6 days 25 days 820 Jejunocolic No Distention Died pre surgeryLevin [1] 22 days 43 days 1190 Jejunoileocolic No Distention Surgery, did wellCase 8 days 10 days 1980 Gastro colic No Increasing bilious aspirates Surgery, did well

S. Kalane et al. / J Ped Surg Case Reports 3 (2015) 10e1212

the barium enema, while other radiological methods play a sig-nificant role to other parameters of the fistulae. The therapy of thiscondition remains surgical. After all, we must emphasize that it is aserious pathologic condition that can lead to death.

Contributions

Kalane S: search of the literature, partial English editing, andcorrection, Suryawanshi P: editing, Vaidya U: Final editing andcorrection, Shrotriya S: editorship of the manuscript.

Conflicts of interestsNone.

Sources of fundingNone.

References

[1] Levin TL, Brill PW, Winchester P. Enteric fistula formation secondary to necro-tizing enterocolitis. Pediatr Radiol 1991;21:309e11.

[2] Hager J, Gassner I. Gastrocolic fistula in a 7 week old: a rare complication aftergastric perforation. J Pediatr Surg 1994;29:1597.

[3] Caffey’s pediatric x-ray diagnosis. 8th ed. Chicago: Year Book Medical Pub-lishers; 1985. p. 1860.

[4] Pein NK, Witswatersrand MB. Neonatal gastrocolic fistula: report of a case.Lancet 1948;II:53.

[5] Firor HV. Gastrojejunocolic fistula in an infant: a previously unrecorded etiol-ogy and reflections on management. J Pediatr Surg 1970;5:450.

[6] Beck JM, Dimner M, Chappel J. Enterocolitis following exchange transfusion.S Afr J Surg 1971;9:39.

[7] Kosloske AM, Martin LW. Surgical complications of necrotizing enterocolitis.Arch Surg 1973;107:223.

[8] Paley RH, McCarten KM, Clevand RH. Enterocolonic fistula as a late complicationof necrotizing enterocolitis. AJR Am J Roentgenol 1979;132:989.

[9] Kiely E, Eckstein HB. Colonic stricture and enterocolonic fistulae followingnecrotizing enterocolitis. Br J Surg 1984;71:613.