1281 Duodenobiliary Fistula: A Rare Complication of Peptic Ulcer Disease

Abstract

INTRODUCTION: Spontaneous biliary enteric fistulas are usually late complications of cholelithiasis or choledocholitiasis. The incidence of biliary enteric fistulas in this population ranges from 0.3 – 0.9%. Biliary enteric fistula formation is usually occurs from a gallstone ulcer perforating into the normal duodenum. However in rare circumstances (3.5-10% of cases) fistula's can form from a duodenal ulcer penetrating into the biliary tree, as is the case with biliary enteric fistula's due to peptic ulcer disease (PUD). These fistula's often present with abdominal pain, malaise and/or hematemesis. We discuss a rare case of a duodenobiliary fistula as a result of long standing peptic ulcer disease. CASE DESCRIPTION/METHODS: A 57-year-old male with long standing abdominal pain who recently immigrated to the United States from the Democratic Republic of Congo presented to the ED with acute on chronic epigastric abdominal pain. He denied previous surgery. Notably, he had tested positive for h. pylori a few months prior and was questionably compliant with prescribed antibiotics. He was admitted with hypokalemia and renal failure. Persistent symptoms prompted a computed tomography (CT) of his abdomen and pelvis. Findings from the CT demonstrated air and oral contrast material within the common bile duct and intrahepatic bile ducts with a fistulous connection to the second portion of the duodenum. Endoscopic evaluation demonstrated esophagitis, gastritis and severe pyloric stenosis likely due to long-standing PUD. The standard endoscope was unable to traverse this stenosis, but was successfully traversed with an ultrathin scope. The ampulla was briefly visualized and was grossly normal. There was no definitive fistulous tract identified. The patient was placed upon high dose proton pump inhibitor therapy. A repeat CT of the abdomen and pelvis was done 6 weeks later and was unchanged. The patient was referred to surgical oncology for definitive management. DISCUSSION: Historically, biliary enteric fistulas were often diagnosed during surgical interventions. Currently, CT can often diagnose these fistulas by detecting minimal pneumobilia. Endoscopic evaluation may or may not demonstrate a biliary enteric fistula due to duodenal narrowing or edema. Antiulcer therapy usually allows clinical improvement and fistula closure for PUD associated fistulas. Surgery is reserved for cases refractory to medical care, poorly controlled symptoms, hemorrhage or biliary obstruction.