**Background:** Gastrojejunocolic fistula (GJF) is a rare, late complication of gastrojejunostomy performed for peptic ulcer disease (PUD). It is believed to result from continuous acid secretion due to insufficient gastric resection or incomplete vagotomy, leading to a stomal ulcer that erodes into the colon. Symptoms typically present 20 years or more after the initial surgery and include chronic on-and-off diarrhea, weight loss, fecal-smelling belching or vomiting, and malnutrition. The preferred diagnostic test is barium enema, with a sensitivity of 95%; upper gastrointestinal endoscopy may also be used. Historically, operative mortality after surgical repair could be as high as 40%, leading to recommendations for staged procedures with preliminary diversion colostomy. With improved perioperative support, single-stage repair is now feasible.
**Methods:** This is a case report prepared in line with the SCARE 2020 criteria. The patient was a 45-year-old man who presented to DELT Hospital, Dire Dawa, Ethiopia, in January 2022. He had a 2-month history of foul-smelling intermittent vomiting, intermittent chronic diarrhea for 2 years, significant weight loss of approximately 12 kg, and epigastric pain. He had undergone upper abdominal surgery 17 years earlier at Hiwot Fana Hospital, Harar, Ethiopia, for recurrent vomiting (records lost). He had no history of smoking or drug use. On physical examination, he was cachectic and dehydrated, with blood pressure 90/60 mmHg, pulse 90 bpm, weight 39 kg, an upper midline vertical surgical scar, and grade 1 pitting pedal edema. Laboratory findings showed hemoglobin 11.7 g/dL (normal 10.0–16.0), albumin 3.2 g/dL (normal 3.8–5.1), and normal serum electrolytes and renal function. Upper GI endoscopy revealed a deformed duodenal bulb and severe stenosis; the stoma was difficult to visualize due to gastrointestinal content despite 24 hours nil per os. Barium study was unavailable. Abdominal CT with contrast was not helpful preoperatively, though postoperative review identified the fistula.
**Key Results:** At exploratory laparotomy, a jejunocolic fistula and retrocolic gastroenterostomy were identified. The GJF was taken down, the gastric stoma and colonic fistula were circumferentially excised, and approximately 10 cm of jejunum was resected. Bowel continuity was restored via jejunojejunostomy, a new gastroenterostomy was created 15 cm from the jejunojejunostomy, and the colonic fistula was refreshed and repaired. The patient stayed in the ICU for 48 hours, began sips on postoperative day 6, advanced to a full diet by day 10, and was discharged on day 12 with instructions for regular follow-up and lifelong proton pump inhibitor (PPI) therapy. Recovery was uneventful. At 2-month follow-up, the patient had gained 5 kg, reported feeling well, and had resumed work as a taxi driver.
**Clinical Implications:** GJF is a rare but serious late complication of gastrojejunostomy for PUD. Although the incidence of surgery for PUD has declined due to medical advances (H2 receptor blockers, PPIs, H. pylori eradication), the long latent period (often >20 years) means that GJF may still present in patients with prior surgery. Clinicians should maintain a high index of suspicion in patients with prior gastric surgery who present with the classic triad of diarrhea, weight loss, and feculent belching or vomiting. Barium enema remains the most sensitive diagnostic test (95%), but endoscopy and CT may also be useful. Preoperative nutritional optimization is critical, and single-stage surgical repair is now the preferred approach given improvements in perioperative care. This case highlights that GJF can be diagnosed intraoperatively even when preoperative imaging is inconclusive, and that a single-stage repair can yield excellent outcomes.