S3384 Choledocystoduodenal Fistula Effectively Treated With a High-Dose Proton Pump Inhibitor: A Case Report

Abstract

Introduction: Choledocystoduodenal fistulas are a rare complication of biliary or peptic ulcer disease. Approximately 91%-94% of spontaneous internal biliary fistulas are caused by stones in the biliary tract. The second most common cause is peptic ulcer. We present a case of a patient found to have a choledocystoduodenal fistula caused by peptic ulcer disease successfully treated with high-dose PPI. Case Description/Methods: A 73-year-old female with a history of duodenitis and gastritis presented for chronic intermittent abdominal pain. Physical exam was positive for epigastric tenderness. Labs were normal. Imaging revealed a large stool burden, mildly distended gallbladder without gallstones and a normal biliary tree. She was started on a once-daily PPI and a bowel regimen. EGD was performed and demonstrated a large necrotic duodenal lesion with copious purulent drainage (Figure A). Gastric biopsy was negative for H. pylori. The patient was readmitted for persistent abdominal pain, weight loss and loss of appetite. On physical exam, she had epigastric tenderness. She was afebrile and lab work was normal. CT abdomen and pelvis demonstrated small bowel thickening involving the duodenal bulb and first portion of the duodenum and air within the gallbladder with mild pericholecystic inflammatory changes. An EGD performed thereafter revealed the same duodenal bulb ulcer with a likely fistula (Figure B); injection of contrast through the tract under fluoroscopy confirmed a fistula to the gallbladder (Figure C). The patient was discharged on high-dose twice daily PPI, a short course of amoxicillin and clavulanic acid. Her symptoms resolved within 8 weeks. A surveillance EGD performed to assess healing demonstrated a healed scar at the site of the prior ulcer and fistula (Figure D). Discussion: Cholecystoenteric fistulas are a rare complication of gallstone disease and peptic ulcer disease, with an autopsy reported incidence rate of 0.1%-0.5%. Historically, surgical treatment is the most common treatment method for cholecystoenteric fistulas. Our case suggests that a high proton pump inhibitor dose for 8-12 weeks may be sufficient for the fistula to heal. By implementing medical management for this condition, it may be possible to avoid the morbidity and mortality associated with laparoscopic or open fistula repair.Figure 1.: A. Initial EGD showing large necrotic duodenal lesion with copious purulent drainage B. Second EGD demonstrating duodenal bulb ulcer C. Fluoroscopy with contrast injection demonstrating fistula tract communication with gallbladder D. Follow-up EGD after treatment with high dose PPI demonstrating healed choledocystoduodenal fistula with a small residual duodenal ulcer.