Choledochoduodenal Fistula (CDF) in a Patient Presenting with Seizure

Abstract

FigurePurpose: A 59 year-old Haitian man presented to our hospital with chronic intermittent vomiting for nearly 10 years. On admission, the patient developed an episode of grandmal seizures for the first time. The patient had a history of hypertension, hypercholesterolemia, chronic renal insufficiency and no prior surgeries. He was on antihypertensive medications and a lipid lowering agent. The laboratory studies revealed: Hgb12.0 g/l, HCT36.0%, WBC 9.1 K/mm3 and PLT 306 K/mm3. His serum electrolytes: Sodium 140 mEq/l, potassium 3.1 mmol/l, chloride 68 mmol/l, bicarbonate 58 mmol/l, calcium 9.9 mg/dl, blood urea nitrogen 55 mg/dl, serum creatinine 4.6 mg/dl. The liver profile was normal. The blood PH was 7.41, and urine PH was 9.0. Abdominal sonogram – was intended to evaluate his kidneys – discovered the presence of Pneumobilia. Abdominal CT scan confirmed this finding, and displayed gastric wall thickening with distended duodenum. EGD grossly showed deformed duodenal bulb with an abnormal aperture of 3–4 mm in diameter in the posterior part of the bulb of duodenum. Upper GI series subsequently showed reflux of contrast material in the non-dilated biliary tree, confirming the presence of CDF (Fig). Later, gastric biopsies indicated positive invasion of helicobacter pylori. During the following days of hospitalization: the renal function improved, the alkalosis resolved, and he was discharged on anti-helicobacter pylori treatment (ampicillin, lansoprazole and clarithromycin). Unfortunately, the patient failed to appear for his follow up appointments. Conclusion: Bilioenteric fistulas are usually incidental findings because they seldom produce clinical symptoms. While Cholecystoduodenal fistulas account for ninety percent of bilioenteric fistulas, choledochoduodenal fistulas are rare. Based on our literature search and findings, this is the first case of CDF presenting with grand-mal seizure. The severe metabolic alkalosis, induced by vomiting in the setting of biliary fistula, appeared to be the contributing disorder. Therefore, physicians should be aware of atypical presentations of CDF and prevent a potentially serious complication.[figure1]