Hepatico-Colonic-Cutaneous Fistula: A Rare Entity Treated by ERCP

Abstract

A 53 year-old woman diagnosed with choledocholithiasis was submitted to an elective laparoscopic cholecystectomy. After two days, presented with abdominal pain, leucocytosis and subhepatic collection in ultrasonography. An emercency laparoscopy was performed and the collection was drained. 35 days later, she presented at the emergency department with bilious enteric secretion through the drain orifice. Transcutaneous fistulography showed contrast media on the colon and the biliary tree. As the patient did not have symptoms of peritonitis, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and confirmed a right hepatic duct fistula with the colon. Papilotomy was performed and a 10Fr/12cm plastic stent was inserted. The patient was submitted to a colonoscopy 35 days later, which showed no signs of fistula. Another 40 days later an ERCP was performed, the stent was removed and no evidence of fistula was seen. The patient had an uneventful evaluation with closure of the cutaneous fistula. The hepaticocolonic fistula is a very rare disease, usually secondary to a local infectious process (cholecystitis), and iatrogenic causes. The most common types are the choledochoduodenal (70%) and choledochocolonic (26%). It is an unusual complication after cholecystectomy, and its mechanism consist in the formation of an internal biliary collection secondary to biliary leak that erodes into the colon, forming the fistula. The clinical signs include right upper quadrant pain, vomiting, nausea, with or without peritoneal signs, and even sepsis. In the diagnostic management are included ultrasound, computed tomography, percutaneous transhepatic cholangiography, magnetic resonance cholangiopancreatography, and ERCP. The gold standard treatment is surgical (open cholecystectomy and segmental colonic resection), however ERCP and sphincterotomy may reduce the intrabiliary pressure and help the fistula close, and this can be the treatment of choice in some cases. There are very few cases of bilio-colonic fistula demonstrated in the literature and most of them were treated by surgery. On the other hand this described case was treated successful by using ERCP approach.