Clinical and Roentgen Aspects of Internal Biliary Fistulas

Abstract

Internal biliary fistulas have been reported mainly on the basis of findings at surgery or necropsy. In an extensive review of the literature the incidence of such fistulas (in the larger groups reported) at the time of routine biliary surgery was found to be as follows: While many unusual fistulas have been described, the main types are cholecystoduodenal, cholecystocolic, and choledochoduodenal. Of 819 cases reported with surgical findings, only 9 per cent were in locations other than one of these three sites (Table II). Such a summary of the literature yields a total number of cases large enough for accurate evaluation of the anatomic and pathologic factors involved. Etiologic Factors The reported frequency of the various etiologic factors of internal biliary fistula has been fairly consistent. Gallbladder calculi, as the primary cause, are listed in 85 to 90 per cent of all surgical series; these include principally the cholecystic fistulas. Garland and Brown (8) point out that “if a gallstone can be detected or there is a reliable history of its presence, a spontaneous internal biliary fistula is apt to be cholecystoduodenal.” Tracey and McKell (4) state that, when stones are not found in a cholecystic internal fistula, one can suspect that they have been passed without the patient's knowledge. In the series of such cases reported from the Mayo Clinic (1), the approximate 3:1 ratio of females to males is in accord with the known sex incidence of cholelithiasis in relation to the development of fistulas. This association is well demonstrated by the following cases of cholecystoduodenal fistula (Cases I–III). Case I (C. H.): One week prior to emergency admission to the hospital, an 85-year-old white woman began to experience progressive flatus and epigastric distention. Two days preceding hospitalization, there was increasing upper abdominal distention, with associated vomiting. Examination showed the upper abdomen to be distended and revealed visible peristalsis. A clinical diagnosis of obstruction of the small intestine was made. The white blood cell count was 20,000, with 95 per cent polymorphonuclears. X-Ray Studies: Barium enema films were not remarkable except for atypical gas shadows in the right upper quadrant, apparently of gallbladder origin (Fig. 1A). There was no evidence of intestinal obstruction. Gastro-intestinal films were then obtained, but unfortunately surgical exploration was performed prior to their interpretation. The reported operative finding was duodenal obstruction by an indurated mass including the omentum, diagnosed grossly as a malignant neoplasm. A gastro-enterostomy was performed. Subsequent interpretation of the gastro-intestinal films showed an unusually large rounded duodenal bulb with a central lobular defect. The biliary tree was partially filled by barium through a fistulous opening between the duodenal bulb and the fundus of the gallbladder (Fig. 1B).