Abdominal imaging
Case TypeClinical Cases
Authors
Lakshmi Priyanka Pappoppula MBBS1, Adedayo Oduwole, MD2, Shreyu Umapathy2, Dr Sridhar Subbaramia, MD3, Dr Jayanth Keshavamurthy MD4
65 years, male
A 65-year-old patient presented with right-sided upper abdominal pain, nausea, loss of appetite and weight for several months. He was admitted for further investigation and evaluation.
CT abdomen: Portal venous phase showed an inflammation, ill-defined fluid collections adjacent to the gallbladder (GB) and anterior to the liver. Air in the gallbladder fossa and in the duodenum raised the suspicion for a cholecystoduodenal fistula.
ERCP: Difficulty in cannulation of the common bile duct, pancreatic duct stent placed.
Post ERCP CT: Inflamed GB with air in the GB fossa with severe pericholecystic inflammatory changes.
Percutaneous transhepatic cholangiogram (PTC): Confirmed a communication between the gallbladder and the duodenum.
Background
Cholecystoenteric fistula is an uncommon complication of gallbladder disease, occurring in 0.06% - 0.14% of patients with biliary disorders [1]. The most common type of cholecystoenteric fistula is the cholecystoduodenal fistula followed by cholecystocolonic fistula [2]. These fistulas are believed to occur as a result of inflammation in the gallbladder, particularly due to chronic cholecystitis [3]. However, they can also occur as a consequence of cancer, trauma, peptic ulcers and diverticulitis [4].
Clinical Perspective
The patients usually present with a vague abdominal pain, diarrhoea, jaundice, weight loss, nausea and vomiting [2] as was seen in our patient which prompted investigations.
Imaging Perspective
None of the imaging modalities have proven to be highly sensitive for the detection of cholecystoenteric fistula [2]. However, the initial diagnostic evaluation is done with abdominal ultrasound or CT scan as for any abdominal pain. Endoscopic retrograde cholangiopancreatography (ERCP) is performed if a cholecystoenteric fistula is suspected. Percutaneous transhepatic cholangiography (PTC) is typically reserved for the patients who are not candidates for ERCP or those who fail ERCP.
Outcome
The cholecystoenteric fistula is treated with fistulectomy, cholecystectomy and if necessary common bile duct exploration [1]. Our patient underwent a satisfactory PTC placement of a cholecystostomy drain and 8 weeks later underwent cholecystectomy which confirmed chronic cholecystitis and perforation without any evidence of cancer.
Take Home Message
The cholecystoenteric fistula is a rare entity. The physicians should always have a high index of suspicion as severe cases may result in complications like perforation of the colon, and faecal peritonitis progressing to sepsis and death.
Written informed patient consent for publication was obtained.
[1] Glenn F, Reed C, Grafe WR (1981). Biliary enteric fistula. Surg Gynecol Obstet ;153:527–532 (PMID: 7280941)
[2] Costi R, Randone B, Violi V, et al (2009). Cholecystocolonic fistula: facts and myths. A review of the 231 published cases. J Hepatobiliary Pancreat Surg. 16:8–18 (PMID: 19089311)
[3] Abou-Saif A, Al-Kawas F (2002). Complications of gallstone disease: Mirrizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J Gastroenterol. 97:249–254 (PMID 11866258)
[4] Goenka P, Iqbal M, Manalo G, Youngberg GA, Thomas E (1994) . Colo-cholecystic fistula: an unusual complication of colonic diverticular disease. Am J Gastroenterol. 94:2558–2560 (PMID: 10484027)
| URL: | https://eurorad.org/case/16609 |
| DOI: | 10.35100/eurorad/case.16609 |
| ISSN: | 1563-4086 |
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
