Cholecystoduodenal Fistula: A Rare Cause of Massive Upper GI Bleeding

Abstract

Introduction: Upper gastrointestinal bleeding is a common medical problem. While peptic ulcer disease, varices, tears, gastritis, angiectasias, or malignancy are the common etiologies, unusual causes should always be included in the differential diagnosis. We present a case of a cholecystoduodneal fistula that presented with massive upper GI bleeding. Case Report: A 75-year-old female patient with a history of myelodysplastic syndrome, coronary artery disease, GERD, and hypertension presented with weakness and vomiting, fevers, and altered mental status x 1 day. She was febrile to 104°F, BP 94/52, and HR 102. Initial labs were significant for a WBC count of 24,700 and a Hb of 7 gm. On admission, she had an episode of hematemesis and bright red blood per rectum, and became hypotensive with positive orthostatics. After initial resuscitation, upper endoscopy was performed and showed old blood in the fundus with no source for the bleeding. The next day, she had a recurrent episode of massive hematemesis. A repeat EGD showed bubbles emanating from the papilla with normal gastric mucosa. A CT and MRCP showed pneumobilia with air extending to the duodenal bulb and the presence of multiple gallstones. The findings were compatible with persistent cholecystoduodenal fistula and a decompressed gallbladder. Blood cultures confirmed gram-negative sepsis. The patient was treated with broad spectrum IV antibiotics and improved clinically. Cholecystectomy was not performed for reasons unknown. One year later, the patient presented with chronic weakness, decreased appetite, and weight loss. Labs were significant for WBC count of 15,630, an AST of 225 IU/L, ALT of 207 IU/L, and alkaline phosphatase of 697 IU/L. CT scan and MRI of the abdomen and pelvis revealed a 4.7-cm mass with biliary obstruction at the level of the porta hepatis with obliteration of the previous choledocystoduodenal fistula. Biopsies confirmed gallbladder carcinoma, and a subsequent ERCP was performed with successful palliative biliary stent. Discussion: Rare complications of gallbladder disease include fistula formation, which can lead to further complications, including pneumobilia, recurrent cholangitis, Mirizzi’s syndrome, Bouvaret’s syndrome, and gallstone ileus. In cases of unexplained massive upper GI bleeding, careful inspection of the papilla may help rule out hemobilia. In this case, the diagnosis of hemobilia helped lead to the immediate treatment and management of a complicated cholecystoduodenal fistula. Conclusion: Cholecystoduodenal fistula is an uncommon complication of gall stone disease, and due to the rarity and variability in which it manifests, a high degree of suspicion must be present at the start to reduce morbidity and mortality.