Roentgen Diagnosis of Spontaneous Internal Biliary Fistulae, Especially Those Involving the Common Duct

Abstract

Spontaneous internal biliary fistulae are not common. In a series of 10,866 autopsies reported by Roth, Schroeder, and Schloth (33) only 43 cases were found. These fistulae may occur between the gallbladder or common duct and any of the adjacent portions of the gastrointestinal tract, stomach, duodenum, or colon. Fistulae between the gallbladder and duodenum are the most common; those between the gallbladder and colon are next in frequency; those between the gallbladder and stomach and those involving the common duct are rarer. In a series of 200 cases of internal biliary fistulae reported by Naunyn (27), 93 were cholecystoduodenal; 49 cholecystocolic; 8 cholecystogastric; and 15 choledochoduodenal. The roentgen diagnosis of spontaneous internal biliary fistula has been made in many instances. The first case so diagnosed was reported by Hunt and Herbst (18) in 1915, and was shortly followed by a case described by Carman and Miller (9). Prior to 1930 only a few examples were recorded, but since that time reports have been increasingly numerous. In a series of fistulae reported by Judd and Burden (20) in 1925, only one out of 153 had been demonstrated by x-ray examination. Having been fortunate enough to recognize several cases in vivo, we were attracted to the problem of differentiating the exact anatomical type of fistula present, with special attention to the correct diagnosis of choledocho-enteric fistulae. Of 10 cases of spontaneous internal biliary fistula found in the records of the San Francisco Hospital from 1931 to 1940, 7 were examined roentgenologically, and 5 of these were correctly diagnosed at the first visit to the department. Two of these fistulae were found to be of the choledochoduodenal type. The details of these cases are summarized in Table I. In 1934 Sickels and Hudson (34) reported the correct roentgen diagnosis of a spontaneous internal biliary fistula and reviewed the literature on 29 other cases which had been so diagnosed. A recent review reveals that 55 additional cases of spontaneous internal biliary fistula have been so diagnosed, which, with the 5 roentgenologically diagnosed cases reported here, make a total of 90 cases which have been disclosed by x-ray examination. Table II classifies these cases according to the type of fistula found, and its cause or apparent cause. From this table it is seen that while cholecystoduodenal fistula is the most usual type, choledochoduodenal fistula is of relatively more frequent occurrence than is indicated by pathological and surgical reports. Etiology The most common cause of these fistulae is calculous perforation. This holds true particularly for the cholecystoduodenal fistulae. Perforating peptic ulcers are also a frequent cause. A few cases are due to carcinoma, either of the gallbladder or stomach, and still fewer to infection, such as acute cholecystitis or empyema of the gallbladder.