Complete Biliary Obstruction Without Jaundice

Abstract

Question: A previously healthy, 41-year-old woman initially presented with abdominal pain and was diagnosed with choledocholithiasis by ultrasound. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed choledocholithiasis (Figure A, B) and the stones were successfully removed with a sphincterotomy and balloon sweep. She underwent an elective cholecystectomy 5 months later, which she tolerated well. She had a normal postoperative recovery without any immediate complications. Ten months after the surgery, she returned with intermittent fevers of 4 weeks' duration and was found to have abnormal liver function tests (LFTs). On physical examination, she was in no acute distress and her vital signs were within normal limits. She had no evidence of jaundice, and her abdominal examination was benign. No hepatomegaly was noted. Laboratory values included: Aspartate aminotransferase, 168 U/L; alanine aminotransferase, 225 U/L; alkaline, phosphatase 354 U/L; and total bilirubin, 1.9 mg/dL. Repeat ERCP found a patent prior biliary sphincterotomy site and an abrupt truncation of the bile duct at the level of surgical clips (Figure C). Despite pressure injection, no contrast entered the bile duct proximal to the clips. Why is this patient not jaundiced and acutely ill? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Percutaneous cholangiography (PTC) demonstrated a fistulous tract connecting the common hepatic duct (Figure D) to the ascending colon (Figure E). Subsequently, she underwent hepaticojejunostomy and had an uneventful postoperative course. In this patient, the biliary–colonic fistula developed as a result of surgical ligation of the common bile duct that led to a chronic bile leak and subsequent inflammation. She did not present with acute illness and jaundice because the fistula drained bile. She had intermittent fevers that were likely the result of recurrent cholangitis. Biliary enteric fistulae are an extremely rare adverse event after cholecystectomy. It has been estimated that major bile duct injuries occur in 0.55%–1.4% of laparoscopic and 0.1%–0.2% of open cholecystectomies, and fistulae develop in <1% of these injuries.1Munene G. Graham J.A. Holt R.W. et al.Biliary-colonic fistula: a case report and literature review.Am Surg. 2006; 72: 347-350PubMed Google Scholar Most biliary enteric fistulae are cholecystoenteric, and typically occur as a late complication of gallstone disease.2Costi R. Randone B. Violi V. et al.Cholecystocolonic fistula: facts and myths A review of the 231 published cases.J Hepatobiliary Pancreat Surg. 2009; 16: 8-18Crossref PubMed Scopus (76) Google Scholar There have been published reports of biliary colonic fistulae occurring spontaneously in the setting of colonic diverticulitis and liver abscesses; however, there are few reports of postcholecystectomy fistulae. The presentation of a biliary colonic fistula consists of fever, right upper quadrant pain, jaundice, diarrhea, and/or steatorrhea; patients may have abnormal LFTs. Consequences of long-standing fistulae include periductal fibrosis, recurrent cholangitis, and eventual biliary cirrhosis. Expedient diagnosis can prevent the development of chronic liver disease.3Maltz C. Zimmerman J.S. Purow D.B. Gallstone impaction in the colon as a result of a biliary-colonic fistula.Gastrointest Endosc. 2001; 53: 776Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Contrast injection of the fistula by ERCP or PTC is the gold standard for diagnosis. Treatment involves a biliary diversion, typically a hepaticojejunostomy.