S1586 Upper Gastrointestinal Bleeding as a Warning Sign for a Rare Cholecystoduodenal Fistula

Abstract

INTRODUCTION: Cholecystoenteric fistulas are rare, observed in approximately 1 out of every 10,000 cholecystectomies. Its symptoms are usually non-specific, making clinical diagnosis challenging and leading to intraoperative diagnosis. Upper gastrointestinal bleed (UGIB) is an infrequent manifestation of this entity. We present the case of a 71 year old male who experienced an UGIB and was later diagnosed with a cholecystoduodenal fistula intraoperatively. CASE DESCRIPTION/METHODS: A 71 year old man presented to the ED complaining of melena and weakness. Patient was tachycardic and his hemoglobin was 10 gm/dL from a baseline of 15 gm/dL. A CT scan with oral contrast showed a high-density mural thickening of the duodenum that extended contiguously to involve the gallbladder wall and hepatic flexure of the colon (Figure 1). An upper endoscopy was performed that showed the oozing duodenal bulb ulcer with an adherent clot. Endoscopic treatment was unsuccessful due to the location of the ulcer. Interventional radiology performed embolization of the right gastric, right gastroepiploic, and right gastroduodenal artery. His hemoglobin stabilized and the patient was discharged home. Due to his CT findings, he underwent colonoscopy 2 months later. A mass was found in the proximal transverse colon near the hepatic flexure concerning for malignancy (Figure 2). Biopsies showed inflamed granulation tissue but no dysplasia or malignancy. However, due to suspicion of malignancy, the patient underwent right open hemicolectomy with ileocolic anastomosis. Intraoperatively, he was found to have a cholecystoduodenal fistula and required a partial cholecystectomy and repair of the fistula via omental patch. Postoperatively, the patient did well with normalization of his hemoglobin. DISCUSSION: Cholecystoenteric fistulas, most commonly cholecystoduodenal fistulas, are rare and usually a late complication of cholelithiasis disease. The occurrence of severe UGIB due to cholecystoduodenal fistulas is unnusual, making it difficult to diagnose. UGIB is usually caused by a marginal ulcer in a site of erosion by the enteric fistula. In our case, it is likely patient had cholecystodudoenal fistula secondary to a perforating duodenal ulcer rather than cholelithiasis which is the cause in most cases of cholecystoenteric fistula. It appears that his colonic mass was inflammatory from the perforated ulcer. It is important to recognize cholecystoduodenal fistula as an associated complication of duodenal ulcer.Figure 1.: High density mural thickening of the duodenum, extending contiguously to involve the gallbladder wall and hepatic flexure of the colon.Figure 2.: Transverse colon mass found during colonoscopy.