A Rare Complication Of Peptic Ulcer Disease: Spontaneous Choledochoduodenal Fistula

Abstract

Introduction: A 67-year-old man with type II diabetes and hyperlipidemia was admitted with acute onset of left lower extremity weakness. In the ER, the patient began complaining of a sudden onset of sharp, non-radiating back pain. On physical exam, the patient was hypotensive and tachycardic with focal left-sided weakness (2/5) of the lower extremity. He had palpable bilateral radial pulses, but an absence of the left femoral pulse and distal left lower extremity pulses. His abdomen was distended, mildly tense, with minimal tenderness and no pulsatile mass. A CTA of the abdomen showed pneumoperitoneum. An exploratory laparotomy was performed, which revealed a pre-pyloric ulcer buttressed to the gallbladder. A subtotal cholecystectomy and Graham’s patch was performed. Post operatively, the patient developed peritonitis and an EGD showed a perforated duodenal ulcer, which was closed using an endoclip. A subsequent upper GI series revealed a choledochoduodenal fistula along the medial aspect of the distal duodenal bulb. Spontaneous enteric-biliary fistulas are a rare entity caused by gallstones (90%), peptic ulcer disease (6%), and malignancy or trauma (4%). Cholecystoduodenal fistulas represent the most common type (61%-77%), followed by cholecystocolonic (14%-17%), choledochoduodenal (3.5-20%), and cholecystogastric (6%) fistulas. Choledochoduodenal fistulas occur more frequently along the posterior wall and are most common in the duodenal bulb. Enteric-biliary fistulas secondary to duodenal ulcers occur more often in men, whereas fistulas secondary to biliary stones usually occur in women, likely due to the natural sexual predilection of the primary disease process. There are no characteristic symptoms that strongly point to the presence of a fistula. In this case, the patient presented with peripheral vascular disease and the symptoms that mimicked a ruptured abdominal aortic aneurysm. The ulcer recurred and perforated despite multiple attempts at closure and medical therapy. This atypical presentation and poor healing is likely due to his underlying vascular disease.Figure 1: Choledochoduodenal fistula with collection at the end.