CHOLECYSTOGASTRIC FISTULA: A RARE COMPLICATION OF CHOLELITHIASIS/ASCENDING CHOLANGITIS

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Cholecystogastric fistula is an abnormal connection between bile duct and stomach. It is a rare complication of long term cholelithiasis, cholecystitis and cholangitis. We describe an interesting case of this rare presentation in a 97-year-old male presenting with abdominal pain and vomiting. CASE PRESENTATION: A 97-year-old male with multiple comorbidities was admitted with vomiting, abdominal pain and distention. Surgical history was remarkable for choledocholithiasis complicated by ascending cholangitis for which he had undergone ERCP with sphincterotomy and stone removal. Vital signs were stable but physical exam was remarkable for a distended, non-tender abdomen with voluntary guarding on deep palpation. Laboratory investigations showed a serum creatinine of 2.2 mg/dL (baseline 1.5-1.7). Other laboratory investigations and infectious workup including blood/urine cultures and hepatitis profile were negative. Abdominal film showed persistent dilated small bowel loops suggestive of diffuse small bowel ileus or obstruction. Ultrasound of abdomen showed gallstones and dilated common bile duct (CBD) with air in the biliary tree. Further imaging with CT/MRI abdomen revealed a fistulous communication between the gastric antrum and the gallbladder/CBD. The patient was managed conservatively given his age and multiple comorbidities. DISCUSSION: Enteral fistulae are abnormal connections resulting from chronic inflammation between tightly adherent walls. They can be congenital or acquired, internal or external. Cholecystoenteric fistulae are of three types: (I) cholecystogastric, (II) cholecystoduodenal, and (III) cholecystocolonic. The rarest among the three are cholecystogastric fistulae and they are associated with significant morbidity and mortality. Underlying etiologies include cholecystitis, cholangitis, trauma, inflammatory bowel disease, peptic ulcer disease and gastrointestinal tract malignancies. Outcomes can vary from clinically silent fistulas to gall stone ileus, cholangitis, peritonitis or gastrointestinal hemorrhage. Abdominal film, ultrasonography, barium studies and CT are most common used modalities for diagnosis. Percutaneous transhepatic cholangiography, ERCP or magnetic resonance cholangiopancreatography can give more specific details but are more invasive and hence were not appropriate for our patient. Treatment is mostly surgical either open, laparoscopic or endoscopic. Our patient had significant co-morbidities and poor functional status and therefore had to be managed conservatively. CONCLUSIONS: This case brings to light a relatively rare complication of cholelithiasis and cholangitis. Reference #1: Cholecystogastric fistula: a brief report and review of the literature. Boland MR, Bass GA, Robertson I, Walsh TN. J Surg Case Rep. 2013 Apr 24;2013(4). pii: rjt028. https://doi.org/10.1093/jscr/rjt028. Reference #2: Laparoscopic management of cholecystoenteric fistula: A single-center experience. Li XY, Zhao X, Zheng P, Kao XM, Xiang XS, Ji W. J Int Med Res. 2017 Jun;45(3):1090-1097. https://doi.org/10.1177/0300060517699038. Epub 2017 Apr 18. Reference #3: Pneumobilia: a case report and literature review on its surgical approaches. Wong CS, Crotty JM, Naqvi SA. J Surg Tech Case Rep. 2013 Jan;5(1):27-31. https://doi.org/10.4103/2006-8808.118616. DISCLOSURES: No relevant relationships by Moses Bachan, source=Web Response No relevant relationships by Muneer Khan, source=Web Response No relevant relationships by Zinobia Khan, source=Web Response No relevant relationships by Mariam Saeed, source=Web Response