1321 A Choledochodoudenal Fistula Without Gallstones: A Case Report

Abstract

INTRODUCTION: Choledochoduodenal fistulas (CDFs) are abnormal connections that form between the common bile duct and the duodenum. CDFs are rare and result from biliary tract diseases like biliary tract stones and/or infections, peptic ulcer disease, Crohn's disease and surgery. They are more common in elderly patients. CDFs may present with cholangitis-like symptoms and the diagnosis is confirmed with endoscopic retrograde cholangiopancreatography (ERCP). Treatment include therapeutic ERCP or surgery. CASE DESCRIPTION/METHODS: Our patient was a 31 year-old Hispanic female who immigrated recently from El Salvador. The patient presented with symptoms of right upper quadrant pain along with nausea/vomiting and low grade fever. Initial laboratories results were remarkable for white blood cell count (WBC) 14.3 × 109 L, acetate aminotransferase (AST) 493 U/L, alanine aminotransferase (ALT) 438 U/L, total bilirubin 2.4 mg/dl, direct bilirubin 0.56 mg/dl, and Alkaline phosphatase 192 U/L. Abdominal ultrasonography showed non-specific gallbladder wall thickening with dilation of the intrahepatic and extrahepatic bile duct (common bile duct diameter of 1.2 cm), and no gallbladder stones (Figure 1). The patient was admitted to the floor and started on broad-spectrum intravenous antibiotics. An urgent ERCP demonstrated a 3 mm choledochoduodenal fistula seen superior to the major papilla. The fistula was draining purulent materials (Figure 2). The common bile duct (CBD) was dilated to 12 mm with no filling defects (Figure 3). The biliary tree was drained and no stones were found (Figure 3). To ensure adequate biliary drainage, a 10 Fr × 5 cm plastic stent was placed into the CBD (Figure 3). Soon, patient clinical and laboratory profile dramatically improved and was discharged two days later with plan for outpatient follow-up. DISCUSSION: We are reporting a unique case of CDF that developed spontaneously in a patient who has no significant past medical history. No underlying pathology like biliary tract stones was found during the ERCP. This case may raise a question that CDFs could be sometimes idiopathic with no predisposing factors. Spontaneous CDFs are uncommon especially in young population. Only few cases in young patients had been reported in literature. The youngest patient reported in literature was a 6-year-old female who had an unusual case of recurrent cholangitis due to CDF.