ACG CASE REPORTS JOURNAL IMAGE | COLON Malignant Coloduodenal Fistula: An Unusual Cause of Vomiting Guru Trikudanathan, MD1, Khalil Farah, MD2, and Mustafa Tiewala, MD2 Division of Gastroenterology, University of Minnesota, Minneapolis, MN Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, MN 1 2 Case Report A 62-year-old black woman was admitted with a 4-day history of nausea and feculent vomiting, a 22-kg weight loss over 6 months, and with hemoglobin of 7.9 g/dL on admission. CT showed asymmetric hypodense, mural thickening of the hepatic flexure with pericolic fat stranding, and an associated loss of interference with the duodenal sweep, suggestive of direct infiltration and suspicious for a coloduodenal fistula (Figure 1). Gastrograffin enema study showed a large, apple core lesion in the ascending colon, suggestive of colon cancer (Figure 2). Colonoscopy revealed a completely obstructing, ulcerated mass in the hepatic flexure; biopsy confirmed poorly differentiated adenocarcinoma of the colon. Upper endoscopy showed feculent material in the stomach and an ulcerated end of a coloduodenal fistula on the posterior duodenal wall with feculent material spurting out (Figure 3). A PET-CT scan showed no evidence of distant metastasis. She was placed without oral intake and started on total parenteral nutrition to optimize her nutritional status. After 1 week, she underwent a sub-total hemicolectomy with en bloc resection of the fistula and primary closure of the duodenal defect. Surgical histopathology confirmed low-grade, moderately differentiated adenocarcinoma of the colon invading the serosa and the wall of the duodenum. The proximal and distal margins and duodenal excision margins were free of disease. Figure 1. Abdominal CT showing asymmetric hypodense, mural thickening of the hepatic flexure with pericolic fat stranding, and an associated loss of interference with the duodenal sweep, suggestive of direct infiltration and suspicious for a coloduodenal fistula. Figure 2. Gastrograffin enema showing a large apple core lesion in the ascending colon, suggestive of colon cancer. ACG Case Rep J 2015;2(3):137-138. doi:10.14309/crj.2015.33. Published online: April 10, 2015. Correspondence: Mustafa Tiewala, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415 (mustafa.tiewala@hcmed.org). Copyright: © 2015 Trikudanathan et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0. 137 acgcasereports.gi.org ACG Case Reports Journal | Volume 2 | Issue 3 | April 2015 Malignant Coloduodenal Fistula Trikudanathan et al Disclosures Author contributions: All authors contributed equally to the creation of this manuscript. M. Tiewala is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report. Received: February 22, 2015; Accepted: March 24, 2015 References 1. 2. 3. Majeed TA, Gaurav A, Shilpa D, et al. Malignant coloduodenal fistulas: Review of literature and case report. Indian J Surg Oncol. 2011;2(3):205–9. Soulsby R, Leung E, Williams N. Malignant coloduodenal fistula: Case report and review of the literature. World J Surg Oncol. 2006;4:86. Yoshimi F, Asato Y, Kuroki Y, et al. Pancreatoduodenectomy for locally advanced or recurrent colon cancer: Report of two cases. Surg Today. 1999;29(9):906–10. Figure 3. Upper endoscopy showing feculent material in the stomach and the ulcerated duodenal end of the coloduodenal fistula on the posterior duodenal wall with feculent material spurting out. With the advent of screening colonoscopy, coloduodenal fistula associated with colon cancer is extremely rare because of early cancer diagnosis and prompt resection. Management includes rehydration, optimizing electrolytes, and improving nutrition through pre-operative total parenteral nutrition.1,2 Definitive surgery involves resection of the tumor and the fistula en bloc with adequate regional lymph node dissection, as performed in our patient. Another curative approach is en bloc pancreaticoduodenectomy, which is associated with reasonable survival.3 Publish your work in ACG Case Reports Journal ACG Case Reports Journal is a peer-reviewed, open-access publication that provides GI fellows, private practice clinicians, and other members of the health care team an opportunity to share interesting case reports with their peers and with leaders in the field. Visit http://acgcasereports.gi.org for submission guidelines. Submit your manuscript online at http://mc.manuscriptcentral.com/acgcr. 138 acgcasereports.gi.org ACG Case Reports Journal | Volume 2 | Issue 3 | April 2015