Simultaneous Cholecysto-duodenal and Cholecysto-colonic Fistulae: an Unusual Complication of Gallstone Disease
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IMAGES IN SURGERY
Simultaneous Cholecysto-duodenal and Cholecysto-colonic Fistulae: an Unusual Complication of Gallstone Disease Manoj K Rangappa 1 & Kishore G S Bharathy 1
&
Anisha S Tandon 2 & Sadiq S Sikora 1
Received: 1 September 2020 / Accepted: 9 October 2020 # Association of Surgeons of India 2020
Abstract Gallstone disease is extremely common worldwide, especially so in India. Internal biliary fistulae are unusual complications of gallstones. Among these the presence of simultaneous fistulae to the duodenum as well as the colon is extremely rare. Diagnosis can be made on careful scrutiny of preoperative cross sectional imaging when performed. Keywords Bilio-enteric fistula . Cholecysto-duodenal fistula . Cholecysto-colonic fistula . CT scan . Gallstone . Complications
A 66-year-old man presented with biliary colic since 2 months, with aggravation of pain since 20 days along with fever with chills since 2 days. There was no jaundice. Ultrasound revealed a contracted thick-walled gallbladder with stones. Liver function tests were within normal limits as was the total leucocyte count. To further characterize the thick-walled gallbladder, a contrast-enhanced computed tomography (CECT) scan was done (Fig. 1). The CT scan clearly depicted the presence of two fistulae (i) between the infundibulum of the gallbladder and the first part of duodenum and (ii) between the fundus of the gallbladder and the hepatic flexure of the colon. Thus, the diagnosis of simultaneous cholecysto-duodenal and cholecysto-colonic fistulae was established. At surgery (laparoscopy, converted to open operation due to dense adhesions), both fistulae were delineated, dismantled, colonic and duodenal edges freshened, and closed primarily. A reconstitutive type of subtotal cholecystectomy was performed. Histopathology revealed features of chronic cholecystitis without any malignancy.
* Sadiq S Sikora [email protected] 1
Department of Surgical Gastroenterology & Liver Transplantation, Sakra World Hospital, SY No.52/2 & 52/3, Devarabeesanahalli, Opposite Intel, Varthur Hobli, Bengaluru, Karnataka 560103, India
2
Department of Radiology, Sakra World Hospital, Bangalore, India
The presence of pneumobilia in the absence of prior endoscopic biliary intervention is a pointer to the presence of a bilio-enteric fistula. Long-standing gallstones with chronic inflammation and pressure lead to necrosis of the common wall between the gallbladder and bowel leading to the establishment of a fistula. Dual fistulae are extremely rare and there are only case reports of this condition. In the series by Chowbey et al. [1] out of 12,428 laparoscopic cholecystectomies performed over 6.5 years, 63 cases of bilio-enteric fistulae were encountered, out of which only one was a dual fistula. In another large series of 10,588 patients who underwent laparoscopic cholecystectomy over a 14-year period, there were 29 cholecysto-enteric fistulae, out of which there was again only one dual fistula [2]. Absence of focal gallbladder wall thickening/massforming lesion
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