P4557 - Fixing the Fistula: A Curious Case of Persistent Coloenteric Fistula

Shoujit Banerjee, MD¹, Bryant Le, MD¹, Michael Andrew Yu, MD², Nabil El Hage Chehade, MD³, Brian Mendoza, MD², Peter H. Nguyen, MD², Jason Samarasena, MD², John G. Lee, MD², Frances Dang, MD^2
1University of California Irvine, Orange, CA; ²University of California, Irvine, Orange, CA; ³Scripps Clinic, San Diego, CA

Introduction: Coloenteric fistulas are abnormal connections that form between the small bowel and colon and may arise as complications from surgery, radiation, malignancy and diverticular disease. This is a case of refractory coloenteric fistula secondary to radiation colitis with multiple novel techniques employed for closure.


Case Description/Methods: An 80-year-old male with history of rectal cancer post low anterior resection and intestinal bypass for small bowel obstruction presented with several months of weight loss and profuse diarrhea. An initial colonoscopy discovered chronic inflammation from radiation and an open fistula entering the small bowel at 25 cm. CT imaging noted a coloenteric fistula proximal to the anastomosis site and barium enema confirmed the fistula between the small bowel and rectosigmoid colon. On repeat colonoscopy, he had a dilated colon with large stool content and a 1-1.5 cm fistula. An over the scope (OTSC) clip was initially placed at this fistula for attempt at closure. However, the patient continued to have diarrhea and repeat sigmoidoscopy showed incomplete closure and stool seepage through the fistula. Therefore, the first clip was removed and a second OTSC clip was placed. However, on repeat endoscopic evaluation, the clip appeared to have migrated. The patient ultimately had a 20 mm waist atrial septal defect occluder placed under endoscopic and fluoroscopic guidance with the addition for definitive fistula closure, which led to significant symptomatic improvement.

Discussion: Gastrointestinal fistulae present significant challenges for endoscopic interventions due to their chronicity and complications that arise from prior interventions. Traditional endoscopic therapies for treating GI fistulas include stents, clip application, and endoscopic sutures. These modalities are limited in fibrotic tissue given difficulty grasping onto the entire tissue involved. The use of cardiac septal occluders in GI fistulas is an emerging technique, with one systematic review showing 100% technical success and 77.27% successful closure rate in 22 known cases.1 Our case illustrates the successful use of a cardia septal occluder for fistula closure and should be considered when other endoscopic tools have failed.

1. De Moura, D. T. H., Baptista, A., Jirapinyo, P., et al., (2020). Role of Cardiac Septal Occluders in the Treatment of Gastrointestinal Fistulas: A Systematic Review. Clinical endoscopy, 53(1), 37–48. https://doi.org/10.5946/ce.2019.030




Disclosures:


Shoujit Banerjee, MD¹, Bryant Le, MD¹, Michael Andrew Yu, MD², Nabil El Hage Chehade, MD³, Brian Mendoza, MD², Peter H. Nguyen, MD², Jason Samarasena, MD², John G. Lee, MD², Frances Dang, MD². P4557 - Fixing the Fistula: A Curious Case of Persistent Coloenteric Fistula, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.