Cholecystocolonic Fistulous Catastrophe!

Abstract

Cholecystocolonic fistula (CCF) is a rare complication of biliary disease with communication between the gallbladder and colon. Patients may present with symptoms similar to that seen in cholecystitis; however, diagnosis is often made intraoperatively and rarely with barium enemas. This gastrointestinal (GI) complication which is classified under biliary-enteric fistula comprises less than 0.2% of all biliary tract disease. We present a rare case of CCF complicated by a catastrophic cystic artery hemorrhage presenting as a lower GI bleed. An 87 year-old male with a past medical history of abdominal aortic aneurysm status post graft presented with syncope preceded by multiple episodes of bloody diarrhea. He had no other GI complaints. On admission, his hemoglobin was 4.5 g/dL and hemodynamically unstable, requiring transfer to the ICU where vasopressors and a massive transfusion protocol were initiated. CT angiography of the abdomen was performed to evaluate for possible aortoenteric fistula. This revealed gangrenous cholecystitis and blood in the hepatic flexure of the large intestine. A colonoscopy was performed revealing blood protruding from a 15 mm fistulous opening at the hepatic flexure. Both epinephrine was injected and one hemostatic clip was placed without achievement of hemostasis. Upon further radiographic review, it was revealed that he had a CCF with a hemorrhagic cystic artery. Given this, he was taken to interventional radiology where they appreciated bleeding from the cystic artery into the CCF at the location seen on colonoscopy. Cystic artery embolization was done with hemostasis and stabilization of the patient's hemoglobin. He received 28 units of packed red blood cells during his hospitalization and was discharged after surgical consultation. CCFs are rare occurrences in the field of gastroenterology. Studies have shown that the typical picture of CCF consists of a triad of symptoms-diarrhea, right hypocondrium pain, and cholangitis. Etiologies can include cholecystitis, malignancy, and cholelithiasis with a track being formed along the track of the gallstones as they erode through the inflamed gallbladder into adjacent bowel. Furthermore, CCF can in unique cases be extensively complicated by mass GI hemorrhage as reported here and treatment can include surgical and endoscopic options. Overall, CCF is a rare phenomenon, but should be included in a differential diagnosis for diarrhea and the triad of symptoms mentioned earlier.