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Scientific letter
Synchronic finding of a foreign body in colon and a malignant gastrocolic fistula
Hallazgo sincrónico de un cuerpo extraño en colon y una fístula gastrocólica de etiología maligna
Enrique Alfaroa,
Corresponding author
kike_almajano@hotmail.com

Corresponding author.
, Viviana Laredoa, Pablo Cañamaresb, Daniel Abada, Gonzalo Hijosa, Sandra García Mateoa, Raúl Velamazána, María Hernándeza, Nuria Sauraa, Ángel Ferrandeza
a Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Hospital San Jorge, Huesca, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopic and radiological images of the foreign body and gastrocolic fistula A&#41; Image of the foreign body embedded in the sigmoid colon&#46; B&#41; CT&#58; fistulous path &#40;arrow&#41; between the gastric corpus and the left colon&#46; C&#41; Splenic flexure with ulcerated mucosa and impassable stenosis&#46; D&#41; Raised lesion with depressed centre suggestive of the gastric portion of the gastrocolic fistula&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Gastrocolic fistulas can have numerous aetiologies&#44; both benign and malignant&#46; Benign entities include peptic ulcers&#44; acute or chronic pancreatitis&#44; and Crohn&#39;s disease&#46; In western countries&#44; the most common malignant aetiology is colon adenocarcinoma&#44; while in eastern countries it is gastric adenocarcinoma&#46; The incidence of a malignant fistula is very low&#58; they appear in only 0&#46;3&#37;&#8211;0&#46;4&#37; of patients undergoing surgery for a digestive neoplasm&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most common clinical manifestations are feculent vomiting&#44; abdominal pain&#44; diarrhoea and weight loss&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of an 80-year-old patient with a history of a cholecystectomy and a hiatal hernia operated by a posterior Toupet-type fundoplication&#46; The patient presented for an outpatient colonoscopy for a microcytic anaemia study&#44; in which&#44; 25&#160;cm from the anal verge&#44; an elongated foreign body embedded at both ends &#40;bone fragment&#41; was observed&#44; with the surrounding mucosa oedematous and erythematous &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; It was extracted in a second stage&#44; 24&#160;h later&#44; using a foreign body forceps&#44; and an abdominal computed tomography &#40;CT&#41; scan was performed showing a 45&#160;&#215;&#160;38-mm mass in contact with the greater curvature of the stomach and splenic flexure of the colon that suggested communication between the lumen of both structures &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Clinically&#44; the patient reported postprandial dyspepsia and anorexia&#44; with a weight loss of 3&#160;kg in 6 months&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The study was completed with a gastroscopy in which a 3&#8722;4&#160;cm lesion with a depressed central area and raised margins with an inflammatory appearance&#44; suggestive of a fistula &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41; was observed in the gastric corpus&#44; with an endoscopic ultrasound in which a solid 40&#160;mm&#160;&#215;&#160;40&#160;mm mass was observed that encompassed the gastric wall and communicated with the colon&#46; A further colonoscopy revealed a mucosa with multiple ulcerations and an impassable stenosis at the splenic flexure &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The biopsies were consistent with a moderately differentiated adenocarcinoma of gastric origin &#40;CDX2 and CK20 positive immunohistochemical study&#44; with weakly positive CK7&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Therefore&#44; the patient synchronously presented a foreign body lodged in the sigmoid colon and a malignant gastrocolic fistula&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The detection of foreign bodies in the colon is rare&#44; since they are usually expelled spontaneously once they have reached it&#46; Diagnosis is usually related to the appearance of a complication&#44; such as intestinal perforation or digestive bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Moreover&#44; the detection of gastrocolic fistulas is exceptional&#46; These&#44; as occurred in our patient&#44; usually communicate the greater curvature of the stomach with the distal half of the transverse colon&#44; since at this point both organs are only separated by the greater omentum&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There are 2 hypotheses to account for the formation of fistulas between the upper and lower digestive systems&#46; The tumour can invade the adjacent organ through the greater omentum or cause&#44; secondary to an ulcer&#44; an intense peritoneal inflammatory reaction that produces adherence and subsequent fistulisation between both organs&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnostic methods include abdominal CT scan&#44; gastroscopy&#44; colonoscopy or a barium meal&#44; which is the most sensitive procedure &#40;up to 90&#37;&#41;&#46; Gastroscopy and colonoscopy are important&#44; since they allow direct visualisation of the fistula and the taking of biopsies&#44; although small fistulas may go unnoticed&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Treatment is usually surgical&#44; individualised in each patient based on tumour staging and comorbidities&#44; although if possible an en bloc resection of the affected area with combined adjuvant chemotherapy is performed in some cases&#46; The data available on the long-term post-surgical survival of these patients are scant&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our patient&#44; an en bloc resection was indicated&#46; However&#44; during surgery&#44; the tumour&#39;s unresectability was confirmed&#44; since it infiltrated the root of the mesenteric vessels&#44; whereupon the decision to perform palliative surgery&#44; consisting of a feeding jejunostomy and a colostomy in the ascending colon&#44; was taken&#46; The patient died three months later&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; malignant gastrocolic fistulas are infrequent&#46; Diagnosis requires computed tomography&#44; colonoscopy and gastroscopy&#44; and treatment&#44; when possible&#44; consists of en bloc resection of the affected area&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alfaro E&#44; Laredo V&#44; Ca&#241;amares P&#44; Abad D&#44; Hijos G&#44; Garc&#237;a Mateo S&#44; et al&#46; Hallazgo sincr&#243;nico de un cuerpo extra&#241;o en colon y una f&#237;stula gastroc&#243;lica de etiolog&#237;a maligna&#46; Gastroenterol Hepatol&#46; 2021&#59;44&#58;658&#8211;659&#46;</p>"
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