Teaching Case

A 64-year-old female patient with a clinical history of inveterate gallbladder stones, admitted to our Hospital for acute cholecystitis, pancreatitis, abdominal pain, vomiting and fever up to 38°C. Clinical examination revealed a bloated abdomen with sharp pain in the right hypochondrium. Laboratory tests showed a mild increase in the liver cytolysis, cholestasis and leucocytosis indexes.

US demonstrated marked thickening of the gallbladder walls, as well as biliary sludge, gallstones and a dilated common bile duct.
CT scanning was done without contrast medium because of high creatinine values, and showed intra- and extrahepatic aerobilia, air bubbles in the gallbladder and surrounding space.
Barium X-rays of the upper digestive tract showed the presence of a fistula from the duodenal bulb with the gallbladder, a fistula from gallbladder and the proximal transverse colon and a stone in the terminal common bile duct.
MRI confirmed the presence of aerobilia and of a stone in the terminal common bile duct.
Surgical treatment was done, consisting firstly of cholecystectomy and colonic and duodenal suture and then, after identifying the stone in the common bile duct by intraoperative trans-cystic cholangiography, of choledochotomy and extraction of the stone.
Histological examination of the operative specimen yielded a diagnosis of chronic fibroplastic cholecystitis with ample acute inflammation and ulceration phenomena.

Bilioenteric fistulae are a rare, late complication of inveterate gallbladder stones, and have a high incidence of morbidity and mortality in elderly patients. In the elderly population, biliary ileus accounts for up to 4.8% of benign bowel obstructions, but has a high mortality rate (15-18%) [1, 2]. In 70-80% of cases the fistula is cholecystoduodenal, being cholecystocolic and cholecystogastric in 10-20%, while colecystoenteric fistulas are rare [1]. A cholecystocolic fistula is a chance finding in 1 of every 1000 cholecystectomies (0.06-0.14%) [3, 4, 6] and accounts for 8-26% of colecystoenteric fistulae [3, 4, 5]. The etiology is related to the presence of a tumour, parassitosis or diverticular disease, or may be iatrogenic as a consequence of previous surgery. However, in more than 60% of cases it is a complication of gallbladder stones [9], that has a mortality rate ranging from 10% to 15% [10]. In the literature, the association of cholecystoduodenal and cholecystocolic fistulae is an extremely rare observation seen in only 5% of cases [1]. A recent review of the data for the period 1950-2006, on 231 cases of cholecystocolic fistulae, elicited just over 20 cases of an association between a cholecystoduodenal and a cholecystocolic fistula [7].
The symptoms are aspecific, consisting of recurrent abdominal pain, epigastralgia and associated vomiting, in cholecystocolic fistulae, with malabsorption, weight loss and diarrhea [4]. Laboratory tests are not diagnostic of this disease, and may reveal only increased liver cytolysis and cholestasis indexes. This is why a preoperative diagnosis, that could help to reduce the high morbidity and mortality rates associated with this disease, as well as to guide the surgical strategy, is rarely made (only 7.9% of these patients) [4]. The imaging tests, US, X-rays CT and MRI, can help to make a preoperative diagnosis of bilioenteric fistulae, demonstrating aerobilia, stones in the bowel lumen, bowel obstruction (Rigler et al. triad, 1941) [8], as well as the course of the fistula. In our case, barium X-rays of the upper digestive tract showed a high accuracy in identifying both the course of the fistulae and the stone in the common bile duct. Among the various imaging methods performed this method was found to have the greatest diagnostic utility, even if it is little appreciated nowadays, especially by younger radiologists.