{
  "abstract": "A female in her 60s was admitted with a 6-week history of profuse diarrhoea. She had a background of stage 3b squamous cell carcinoma of the cervix diagnosed in 2016 treated with radical chemotherapy and internal radiotherapy, resulting in remission of disease. After 2 years, her cancer relapsed, and she developed bony metastasis in the lumbar spine, treated with further chemotherapy. She had a mixed response to treatment but in late 2021 developed local progression of disease. In 2022 she commenced Pembrolizumab, a checkpoint inhibitor, but this was discontinued in March 2024 due to diarrhoea. She repeatedly declined endoscopic investigations and was treated empirically with Budesonide, having reported previous intolerance to Prednisolone, for presumed immunotherapy-induced colitis, but there was no improvement. Due to a contrast allergy, she had a non-contrast CT in May 2024 which showed stable disease with no cause for diarrhoea. Her symptoms started to deteriorate with profuse diarrhoea, weight loss and fatigue, so she was admitted in June 2024 and finally agreed to flexible sigmoidoscopy. This showed rectal inflammation (figure 1a) and a malignant looking stricture in the proximal rectum (figure 1b). After 10 cm advancement, the scope surprisingly passed into the stomach (figure 1c, d). Following discussion with radiology, it was deemed safe for CT with oral contrast which confirmed a large fistula between the third part of the duodenum (D3) and rectum (figure 2) not visible on initial non-contrast CT. Gastroscopy confirmed the proximal fistula opening in D3 (figure 3). Histology was consistent with squamous cell carcinoma of the cervix. She was managed palliatively and died 1 month later.",
  "authors": [
    {
      "affiliations": [
        "Walsall Manor Hospital, Walsall, UK"
      ],
      "name": "Chelsea Street"
    },
    {
      "affiliations": [
        "Walsall Manor Hospital, Walsall, UK"
      ],
      "name": "Jasvinder Kaur"
    },
    {
      "affiliations": [
        "Walsall Manor Hospital, Walsall, UK"
      ],
      "name": "Alice Deepa"
    },
    {
      "affiliations": [
        "Walsall Manor Hospital, Walsall, UK"
      ],
      "name": "Ella Mozdiak"
    }
  ],
  "title": "Surprising case of chronic diarrhoea",
  "uid": "f29f4be1-48c5-504b-897d-1fb926c9020d"
}