2665 Choledochoduodenal Fistula as the First Sign of Metastatic Ovarian Cancer

Abstract

INTRODUCTION: Choledochoduodenal fistulas (CDF) account for 5–25% of all internal biliary fistulas. They arise from duodenal ulcers or choledocholithiasis. Clinical presentation is non specific, therefore diagnosis necessitates use of imaging modalities. Most tumors that cause obstructive jaundice originate in the biliary tree, however there have been reports of biliary metastasis arising from distant cancer sites. We present the first case of CDF as the initial presentation of metastatic ovarian cancer after years in remission. CASE DESCRIPTION/METHODS: An 83 year old African American female with untreated Hepatitis C, chronic kidney disease, and high grade ovarian serous carcinoma status post exploratory laparotomy and chemotherapy 10 years ago, was admitted to the hospital with undocumented fever and abdominal pain for 4 days. She had right upper quadrant tenderness. Total bilirubin (TB) was 1.3 mg/dl and direct bilirubin (DB) was 0.5 mg/dl. CT scan abdomen showed dilation of the intra and extra hepatic bile ducts. ERCP showed a 13 mm duodenal ulcer superior to the duodenal major papilla with a common bile duct (CBD) stricture. Sphincterotomy and plastic stent placement in CBD was done after which she was discharged home. One month later, she was readmitted with melena for 3 days. Heart rate was 120 beats per minutes with hemoglobin of 5.6 mg/dl from a baseline of 9–10 mg/dl. CA 125 was 162.2 U/ml and alpha-fetoprotein was 7.6 ng/ml. EGD showed a 2 cm necrotic ulcer in the first part of duodenum with a fistulous tract. MRI abdomen showed a fluid collection around the duodenum with a choledochoduodenal fistula. Due to concerns about cancer, a repeat EGD was done for biopsy of the ulcer that showed a poorly differentiated carcinoma with immunoprofile positive for CK7, PAX8, ER and P53, consistent with ovarian cancer. PET scan was negative for any other metastasis. After discussion with the family, no further therapy was planned after which she was discharged home with palliative treatment. DISCUSSION: There have been cases of CDF arising from metastatic cancer invading the biliary tree. Colon adenocarcinoma and other neoplasms of the bile duct have been shown to cause CDF. Ovarian cancer has not been known to metastasize to the duodenum. Our patient was the first ever case of ovarian cancer metastasis to the duodenum that caused a CDF years after remission. Hence, we strongly recommend keeping a high index of suspicion when treating rare conditions like CDF in patients with a history of malignancy.