Open Journal of Clinical & Medical Volume 2 (2016)
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Clinical Medical & Case Reports Open Journal of ISSN 2379-1039 Volume 2 (2016) Issue 22 Ceppa EP Open J Clin Med Case Rep: Volume 2 (2016) Cholecystoduodenocolic Fistula in the Setting of Chronic Cholelithiasis Luke A. Umana; Eugene P. Ceppa* *Eugene P. Ceppa Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States Email: [email protected] Abstract We present a case of a 38-year-old female who presented with several months of symptomatic cholelithiasis. Her laparoscopic cholecystectomy was delayed due to comorbidities allowing for periodic abdominal imaging. Her eventual laparoscopic cholecystectomy revealed two istulas consistent with cholecystoduodenocolic istula. This operation was converted to an open procedure with primary repair of both istula tracts and successful completion of the cholecystectomy. This case highlights the dificulty of obtaining a pre-operative diagnosis of bilioenteric istulas and the importance of converting to a laparotomy when encountered with unclear anatomy. Introduction Bilioenteric istulas are rare with an incidence of 0.74% in all biliary tract surgeries [1]. Cholecystoduodenal and cholecystocolic istulas are the most commonly encountered bilioenteric istulas with an incidence of 71.4% and 14.3%, respectively [2]. Combined bilioenteric istulas are exceedingly rare with only a few reported cases of cholecystoduodenocolic istulas in the medical literature [3-9].These istulas continue to be dificult to diagnose preoperatively despite extensive radiographic studies and pose some intraoperative technical dificulty. We report a inding of a cholecystoduodenocolic istula in a patient with chronic cholelithiasis undergoing laparoscopic cholecystectomy. Case Presentation A 36 year-old African American female presented to the outpatient surgery clinic for elective cholecystectomy evaluation. She was previously evaluated eight months prior when she presented to the emergency department with nausea, vomiting and epigastric pain radiating to her back in the setting of known cholelithiasis. On admission, initial labs were WBC 10.6 k/cumm; Hgb 9.5 gm/dL, platelets 532 k/cumm, total bilirubin 0.8 mg/mL, alkaline phosphatase 82 units/L, ALT 13 units/L, AST 17 units/L and lipase 314 units/L. The patient was afebrile with diffuse abdominal tenderness and no guarding or Abbreviations RUQ: right upper quadrant; MRCP: magnetic resonance cholangiopancreatography; FNA: ine need aspiration; G-J:gastrojejunal; HIDA: hepatobiliary iminodiacetic acid Keywords laparoscopic cholecystectomy; cholecystitis; gallstone; cholecystoduodenocolic istula
Transcript of Open Journal of Clinical & Medical Volume 2 (2016)
Clinical Medical & Case Reports
Open Journal of
ISSN2379-1039
Volume2(2016)Issue22
CeppaEP
OpenJClinMedCaseRep:Volume2(2016)
CholecystoduodenocolicFistulaintheSettingofChronicCholelithiasisLukeA.Umana;EugeneP.Ceppa*
*EugeneP.Ceppa
DepartmentofSurgery,IndianaUniversitySchoolofMedicine,Indianapolis,IN,UnitedStates
Email:[email protected]
Abstract
We present a case of a 38-year-old female who presented with several months of symptomatic
cholelithiasis.Herlaparoscopiccholecystectomywasdelayedduetocomorbiditiesallowingforperiodic
abdominalimaging.Hereventuallaparoscopiccholecystectomyrevealedtwo�istulasconsistentwith
cholecystoduodenocolic�istula.Thisoperationwasconvertedtoanopenprocedurewithprimaryrepair
ofboth�istulatractsandsuccessfulcompletionofthecholecystectomy.Thiscasehighlightsthedif�iculty
of obtaining apre-operativediagnosisof bilioenteric �istulas and the importanceof converting to a
laparotomywhenencounteredwithunclearanatomy.
Introduction
Bilioenteric �istulas are rare with an incidence of 0.74% in all biliary tract surgeries [1].
Cholecystoduodenal and cholecystocolic �istulas are the most commonly encountered bilioenteric
�istulaswith an incidence of 71.4% and 14.3%, respectively [2]. Combined bilioenteric �istulas are
exceedingly rare with only a few reported cases of cholecystoduodenocolic �istulas in the medical
literature [3-9].These �istulas continue to be dif�icult to diagnose preoperatively despite extensive
radiographic studies and pose some intraoperative technical dif�iculty. We report a �inding of a
cholecystoduodenocolic �istula in a patient with chronic cholelithiasis undergoing laparoscopic
cholecystectomy.
CasePresentation
A36year-oldAfricanAmerican femalepresentedto theoutpatientsurgeryclinic forelective
cholecystectomyevaluation.Shewaspreviouslyevaluatedeightmonthspriorwhenshepresentedtothe
emergencydepartmentwithnausea,vomitingandepigastricpainradiatingtoherbackinthesettingof
knowncholelithiasis.Onadmission,initiallabswereWBC10.6k/cumm;Hgb9.5gm/dL,platelets532
k/cumm,totalbilirubin0.8mg/mL,alkalinephosphatase82units/L,ALT13units/L,AST17units/Land
lipase314units/L.Thepatientwas afebrilewithdiffuseabdominal tenderness andnoguardingor
AbbreviationsRUQ:rightupperquadrant;MRCP:magneticresonancecholangiopancreatography;FNA:�ineneed
aspiration;G-J:gastrojejunal;HIDA:hepatobiliaryiminodiaceticacid
Keywordslaparoscopiccholecystectomy;cholecystitis;gallstone;cholecystoduodenocolic�istula
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reboundtenderness.
RUQ ultrasound did not demonstrate de�initive pericholecystic edema or wall thickening.
Incidentally,a2.2cmx2.6cmhypoechoicstructureadjacenttothepancreasheadwasdiscovered.The
patientwasadmittedtothehospitalandwastreatedsymptomaticallyforgallstonepancreatitis.Further
radiographicstudieswereobtainedintheformofaMRCPwhichcon�irmedmultiplegallstones.The
gallbladderwascontractedandincloseproximitywiththeduodenumandtransversecolon.Additionally,
MRCPrevealeda2.7cmx1.8cmx2.5cmenhancingmassalongthesuperioraspectofthepancreas,
periportal lymphadenopathy and peripancreatitic edema around the head of the pancreas near the
secondportionoftheduodenum(Figure1).Twoweekslater,endoscopicultrasoundwithFNAofthe
pancreaticmassandperiportalnodesrevealedanaplastic largecell lymphoma,stageIIa,andgastric
outlet obstruction secondary to lymphadenopathy. A G-J tube was placed for nutrition and
cholecystectomy was postponed until completion of cyclophosphamide, hydroxydaunorubicin,
vincristine,andprednisonetherapy.
Severalhospitalreadmissionsforneutropeniccandidemia,vancomycinresistantenterococcus
urinarytractinfection,andpulmonaryembolismcomplicatedherpre-surgicalcourse.Herunfortunate
preoperativecourseallowedforperiodiccross-sectionalimaging.The�irstCTwithcontrastrevealed
gallstonesunchanged fromherpreviousMRCPobtainedone-monthprioronheroriginaladmission
(Figure2).AsecondCTscanobtainedamonthandhalflatershowedthesameperipherallycalci�ied
stonespresentinthegallbladderwithnobiliaryductdilation(Figure3).Onemonthlater,aHIDAscanwas
performedwhich showed no �illing of the gallbladder consistent with chronic cholecystitis and on
delayedimagingsomegastrointestinalactivityintherightmid-abdomen(Figure4).Onemonthafterthe
HIDAscan,anotherCTwithoutcontrastshowedacontractedgallbladder,calci�iedstonesandanewfocal
hypodensitywithvascularity surrounding thegallbladder.Thiswas interpretedas severe focal fatty
in�iltration(Figure5).Throughoutthesemonths,sheremainedsymptomaticwithintractablenausea,
vomiting, persistent RUQ pain and 27 kg weight loss. After completion of chemotherapy for her
lymphoma,shewasdeemedasurgicalcandidateandconsentedforlaparoscopiccholecystectomyfor
symptomaticcholelithiasis.
Laparoscopicexplorationoftherightupperquadrantrevealedthetransversecolonadherentto
thegallbladder.Thecolonwassuccessfullymobilizedfromthegallbladderutilizingelectrocauteryand
bluntdissection.Atopdowncholecystectomywasperformedduetoaseverelycontractedgallbladder.
Thegallbladderwasnotedtobeseverelyadherenttotheduodenum.Atthispointintheoperation,the
laparoscopicprocedurewasconvertedtoopenprocedurebecauseofunclearanatomyduetotheinability
to dissect the gallbladder off of the duodenum. A communication between the gallbladder and the
duodenumwas divided purposefullywith electrocautery revealing a cholecystoduodenal �istula. No
additional pathology was encountered when the duodenum and retroperitoneum were inspected
followingaKochermaneuver.Thecholecystoduodenal�istulawasrepairedintwolayerswithinterrupted
3-0vicrylsuturesandreinforcedwith3-0silkGambetsutures.Botha4cmand3cmstonewereextracted,
andthecholecystectomywascompletedwithligationanddivisionofthecysticarteryandduct.After
completionofthecholecystectomy,thecolonwasinspectedrevealing2mmfullthicknessopeningwithin
a �ibrous rind on the wall of the colon consistent with a cholcystocolic �istula. A colorrhaphy was
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performedwithtwolayersofinterrupted3-0vicrylsuturesreinforcedwith3-0silkGambetsutures.The
repairwascoveredwithanintraabdominalomental�lap.One19frenchblakedrainwasleftadjacentto
eachrepair.Finalsurgicalpathologyofthegallbladderand�ibrousrindcon�irmedacuteandchronic
in�lammation with no morphological evidence of lymphoma. The patient was discharged on post-
operativedaynineandhadnomajorpost-operativecomplications;thepatientwasmedicallyreadyon
daysevenyetduetochronicpainanddispositiontorehabilitationherdischargewasdelayed.Shewas
seeninclinicatthreeandsixweeksfollowingsurgeryandwastreatedforasurgicalsiteinfectionwith
openingofthewoundandtwicedailypackingofthewoundwhichresolvedatsixweeks.
Discussion
Thiscaseexempli�iedthedif�icultyofestablishingapreoperativediagnosisofcholecystoenteric
�istulas.Thepatient'sanaplasticlymphomadiagnosiswasestablishedusingmultipleimagingmodalities
such as CT andMRI/MRCP,whichwere not sensitive enough to detect the presence of a �istula. In
retrospectivereviewofthepatient'sradiographs,theimagesweresuspiciousfora�istulagiventheclose
proximityof theduodenumand the transverse colonwith thegallbladder.TheT2hasteMRI image
(Figure 1) showed a hypointense gallbladder indicating the presence of air and the possibility of a
bilioenteric �istula. Serial CT imaging from her multiple hospital readmissions demonstrated large
persistentgallstonesincloseproximitywiththetransversecoloninFigures2,3,and5.Additionally,the
closeproximityofthestoneandduodenumcanbeappreciatedbythehyperintenseG-Jtubelocatedinthe
duodenuminFigures2and3.InFigure2B,theblackarrowindicatesevidenceofairinthegallbladder.In
Figure3B,thearrowshowsahypointenseareaconnectingthegallbladderandtheduodenum,whichmay
representacholecystoduodenal�istula.Additionally,theadhesionbetweenthecolonandthegallbladder
canbevisualizedbythearrowinFigure3C.Itwasonlyuntilthepatient'slastCTscan,Figure5,whenthe
hypodensitysurroundingthegallbladderwasinterpretedbytheradiologisttohavevesselscoursing
throughthefattyin�lammation.Wesuspectthismayrepresentthecholecystocolic�istula.InFigure5B,
theadhesionsbetween thegallbladder-duodenumcanbeappreciatedwith theblackarrowand the
adhesion between the gallbladder-transverse colon can be appreciated with the white arrow. By
comparison of serial images, we suspect these connections between the gallbladder and
colon/duodenumcontainedthe�istulatracts.
Themajorityofbilioenteric�istulaspresentasymptomaticallyasaresultofchroniccholelithiasis.
In themedical literature,91-94%of reported �istulasare thought tobesequelaofchronicgallstone
diseasepressurenecrosisatthegallbladderinfundibulum[10].Wesuspecther�istulasarosefroma
combinationofchroniccholelithiasisand27kgweightlossleadingtoaseverelycontractedgallbladder
withpersistentin�lammation.Rarely,�istulaformationresultsfrompepticulcerdiseaseandneoplasms
[11].Wedonotsuspectherdiagnosisofanaplasticlymphomacaused�istulaformation,althoughwe
consideredthisbutthesurgicalpathologycon�irmednomalignancy.Butratherhersigni�icantweight
loss, malnutrition, and acute on chronic cholecystitis contributed to her contracted and necrotic
gallbladderresultinginconditionsfavorablefor�istulaformation.
Ofthefewreportedcholecystoenteric�istulas,cholecystectomyand�istularepairwerecompleted
usingonlylaparoscopictechnique[8].Inthiscase,theunclearanatomyin�luencedthedecisiontoconvert
toopenlaparotomy.Thisallowedforsuf�icientexplorationofthe�ibrousrindonthecolonleadingtothe
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discoveryofthesecond�istula.Withoutthiscrucial�inding,thispatienthadthepotentialtodevelop
serious complications. This patient also had two separate �istula tractswhich is distinct frommost
previousreportswhichreportonecontinuous�istulatractbetweengallbladder,colonandduodenum[1,
3-9].
Thispatientexempli�iedthedif�icultyofdiagnosingbilioenteric�istulaswithoutclassicsequela
suchasgallstoneileus.Additionally,thisreinforcedtheimportancehavingcertainthresholdtoconvertto
open laparotomy when encountered with unclear anatomy. Upon conversion to a laparotomy this
allowedforsuf�icientexplorationandde�initiverepairofthe�istula.
Figures
A B
Figure1:MRCPobtainedonoriginalhospitaladmissiondemonstratingpnuemobilia.
A B
Figure2:AbdominalCTwithcontrastdemonstratingthepresenceofcholelithiasis.(A)Theproximityofthe
duodenumandgallbladdercanbeappreciatedbythehyperintensestructureoftheG-Jtube.(B)Theblackarrow
indicatesthepresenceofpneumobiliasuperiortothegallstone.
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Figure 3: Series of abdominal CT with contrast images obtained approximately 2.5 months after original
admission.(A).Axialimagedemonstratingthepresenceofgallstonesandcloseproximitytotheduodenum.(B).
Theblackarrowindicatesthestructuresuspectedtobeearlysignsof�istulaformation.(C).Thisisdemonstrated
againinanalternantcoronalplane.
Figure4:HIDAscandemonstratingincompletegallbladder�illingsuggestiveofcholelithiasisanddelayedactivity
intherightupperabdomen.
A A B
C
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IntraoperativeImages
Figure 5:Abdominal CT scan without contrast demonstrating interval increase in gallstone size and close
adherencetosurroundingintestinalstructures.(A).Severefocalfattyin�iltrationwithvascularitysurroundingthe
gallbladder.(B).Thewhitearrowindicatesadhesionsbetweenthetransversecolonandgallbladdersuspicious
for a cholecystocolic �istula. The black arrow indicates a similar adhesion connecting the duodenum and
gallbladdersuspiciousforacholecystoduodenal�istula.
A B
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ManuscriptInformation:Received:August16,2016;Accepted:November28,2016;Published:November30,2016
AuthorsInformation:LukeA.Umana;EugeneP.Ceppa*
DepartmentofSurgery,IndianaUniversitySchoolofMedicine,Indianapolis,IN,UnitedStates
Citation:CeppaEP,UmanaLA.Cholecystoduodenocolic�istulainthesettingofchroniccholelithiasis.OpenJClinMedCase
Rep.2016;1192
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