An unexpected finding on gastroscopy: gastro-gastric fistula with Helicobacter pylori and Giardia lamblia
28 May 2013 (online)
A 66-year-old woman presented with a 6-week history of vomiting, dysphagia, black stool, and weight loss, with melena on per rectum examination. Gastroscopy revealed a large chronic ulcer at the incisura with two gastro-gastric fistulae between the antrum and the body ([Fig. 1]). [Fig. 2] shows the proximal endoscope markings visible through a fistula. Biopsies and computed tomography (CT) of the abdomen did not show any evidence of neoplasia, but histologic examination revealed numerous Giardia lamblia parasites ([Fig. 3]). Helicobacter pylori was not seen but the rapid urease test was positive. The patient was treated with intravenous pantoprazole, oral metronidazole, and eradication therapy, and no more bleeding was observed. H. pylori was successfully eradicated and following discharge the patient gained weight with no further signs of gastrointestinal bleeding. Repeat endoscopy showed healing of the ulcer but persistent incisura deformity and gastro-gastric fistulation.
Although peptic ulcer disease, Crohn’s, and cancer have been postulated to cause fistulation, we could find no published data to confirm this. Reports of gastro-gastric fistulae in the literature are almost exclusively related to obesity surgery. This complication occurs in up to 1.2 % of Roux-en-Y procedures,  which seems to be the most common cause of gastro-gastric fistulae. The presence of Giardia seems incidental although it has previously been linked to H. pylori infection  . In a large retrospective case series of patients with giardiasis, 8.7 % had gastric colonization but this was not associated with any specific gastric histology . In addition, since Giardia is not usually associated with ulceration in its more usual habitat of the small bowel , it can be assumed to be an unrelated finding. We believe our patient most likely had chronic peptic ulcer disease related to H. pylori with, perhaps, perforation and subsequent fistula formation.
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