Dear Editor:

A 32 years-old male was admitted due to rectal bleeding and diarrhea started 2 months before. He was pale, with fever and with signs of severe malnutrition. Blood count showed anemia (Hemoglobin 7.7 g/dL), hypoalbuminemia (22 g/dL), and elevated C-Reactive Protein (202 mg/L). Colonoscopy showed an ulcerated stenosis with necrotic tissue proximally in the ascending colon that did not allow progression of the scope. In upper endoscopy, a necrotic cavity was seen in the duodenal bulb and, advancing the scope, we went directly to the colon. Biopsies on both exams were diagnostic of signet-ring cells adenocarcinoma. CT scan also revealed duodenocolic fistula. During surgery, this lesion was considered unresectable, and chemotherapy was not feasible due to his very poor health status. He died 2 months later.

Coloduodenal fistulas are rarely described, and this is the first report of a signet-ring cells adenocarcinoma in this setting. In the literature, we found a few reports from fistulas due to Crohn’s Disease [1] (probably the most common etiology [2]), tuberculosis [3], gallstone disease [4], and malignancy from hepatic flexure [1]. These fistulas are normally detected by cross-sectional studies and the lumen of the fistula is usually narrow. By contrast, in our case, the fistula was very large and it was diagnosed by endoscopy.

Besides, nutritional support, treatment is primary surgical, if possible with an en bloc duodenopancreatectomy. Prognosis depends on the etiology and patient performance status.