Presented by:Ghomadi.S, Allani.R, Ben Messaoud.M, Fourati.E, Menif.EImaging Department-La Rabta Hospital-Tunis-Tunisia

Cholecystocolic fistula:An inusual complication of the cholecystitis.

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Introduction

Spontaneous fistula formation between the gallbladder and colon is an unusual complication of calculous cholecystitis and may be difficult to diagnose clinically because of its non-specific clinical signs and symptoms.

We report a case of spontaneous cholecystocolic fistula revealing a chronic calculous cholecystitis that was diagnosed pre-operatively by multidetector CT.

Case Report:

A 32 years old-man ,with no past history,presented to the emergency complaining of 4 days worsening pain of the right upper quadrant and vomiting.Two months earlier he presented the same symptomatology treated symptomatically.

On physical exam he was subfebrile with 37.7°C and had a sensibility on the right hypochondrium.

Biological exams showed a BIS(biological inflammatory syndrom) ,no cholestaseis nor cytolysis.

We started by performing an abdominal ultrasonography that shown a distended galbladder with wall thickning but in front of the absence of gallstone and the difficulty to explore the cystic duct we completed by CT.

CT findings

Fig 01. Non-contrast axial CT image shows calculus in gallbladder

Fig 02. Oblique sagittal MPR CT image shows the gallbladder limit distension and also a limited wall-thickening.

Fig 03.Contrast-enhanced axial CT image shows the submucosal abscess of the right flexure of the colon

Fig 04. Oblique sagittal and coronal MPR CT images shows the fistulous communication()between the gallbladder and the hepatic flexure of the colon

The patient received 2 days of antibiotics before he undergone surgery;

Peroperative findings were a thickned ,hard-bounded gallblader wall with pseudotumor appearence and many adherences to duodenum and the right colic angle.They proceed to the cholecystectomy and they discover a cholecysto-colic fistula of 8mm that was excised.

Discussion:

Chronic calculous cholecystitis is responsible for over 90% of all biliary-intestinal fistulae.

Gallstone ileus(consequence of cholecystoduodenal fistula),is the most common of these fistula,after that we find the cholecystocolic fistula ,accounting for

10–20% of biliary-intestinal fistulae, and occurs in less than 1% of patients with calculous cholecystitis.

Other causes of biliary-intestinal fistulae include

peptic ulcer disease, trauma, Crohn’s disease, infection, and malignancy(pancreatic, enteric or biliary) .

Clinical diagnosis of cholecystocolic fistula remains difficult because of non-specific clinical presentation.

Reported signs and symptoms include :

right upper abdominal pain that abruptly stops (thought to decompression of the inflamed gallbladder into the colon)

sudden onset lower abdominal pain from a stone obstructing the distal colon and rarely a clinical picture of intestinal lower obstruction,

gastrointestinal hemorrhage from focal ulceration at the site of the fistula . diarrhea due to malabsorption syndrome because of

obstruction of the common bile duct has been reported in about a quarter of patients.

others: fever,nausea,vomiting…

Radiographic findings of cholecystocolic fistulae include unexplained gas in the biliary tract and intracolonic gallstone with or without obstruction.

The role of ultrasound is limited . However, gallbladder wall thickening, cystic duct obstruction, and failure to find a previously identified gallstone may suggest the presence of a cholecysto-intestinal fistula .

CT findings:CT has a triple role:

Suggesting the diagnose include a thick-walled gallbladder that may contains stones(absent if migrate )and almost pathognomic sign is the presence of gas+/- aerobiliae.

In our case, and what it lead the diagnose more difficult, is that the gas was absent because the fistula was sub-mucosal with the developpement of an intra-mural abscess.

Identifying the fistula with axial images alone may prove difficult. However, multiplanar reformations may better depict the fistula, as illustrated in this example.

Complications: cholangitis , abscess, peritonitis with a pneumoperitoneum , intestinal obstruction…

Barium enema, endoscopic retrograde cholangiopancreatography (ERCP) ,

and colonoscopy may also demonstrate the cholecystocolic fistula.

Treatment is mainly surgical in this situation, with an open or laparoscopic cholecystectomy and a resection of the fistula .

Fig 05. Barium enema shows communication between biliary system and colon

Traitement d'une fistule cholécysto-colique par sphinctérotomie endoscopique : à propos de 2 casM. RAMDANI *, G. GALINDO *, G. D'ABRIGEON \ J.P. BARRAU *, O. DUHAMEL *,J. GISLON *, F. BLANC **

Conclusion

Cholecystocolic fistula is an unusual complication of chronic calculous cholecystitis. Signs and symptoms are non-specific, but unexplained diarrhea or pneumobilia ,particularly with known cholelithiasis, should suggest the diagnosis.

MDCT, with its multiplanar reconstruction capabilities, may help in detection of cholecystocolic fistula in addition to its complications.

References

Jeffrey P. Kanne.Multidetector-row CT diagnosis of cholecystocolic fistula.European Journal of Radiology Extra 54 (2005) 31–34.

Correia MF, Amonkar DP, Nayak SV, Menezes JL. Cholecystocolic fistula: a diagnostic enigma. Saudi J Gastroenterol. 2009 Jan;15(1):42-4.

Hussien M, Gardiner K. Omental and extraperitoneal abscesses complicating cholecystocolic fistula. HPB (Oxford). 2003;5(3):194-6.

Wang WK, Yeh CN, Jan YY. Successful laparoscopic management for cholecystoenteric fistula. World J Gastroenterol. 2006 Feb 7;12(5):772-5.

Toll EC, Kelly MD. Successful management of cholecystocolic fistula by endoscopic retrograde cholangiopancreatography: a report of two cases. Hong Kong Med J. 2010 Oct;16(5):406-8.

O' Donoghue GT, Winter D, Deasy J.Cholecystocolic fistula and large-bowel obstruction due to gallstone ileus. Arch Surg. 2003 Dec;138(12):1391-2

Velayos Jiménez B, Gonzalo Molina MA, Carbonero Díaz P, Díaz Gutiérrez F, Gracia Madrid A, Hernández Hernández JM.

Cholecystocolic fistula demonstrated by barium enema: an uncommon cause of chronic diarrhoea. Rev Esp Enferm Dig. 2003 Nov;95(11):811-2, 809-10