Spontaneous Cholecystoduodenal Fistula in a Patient with a Primary Hepatoma of the Liver

Abstract

A case of spontaneous cholecystoduodenal fistula in a patient with a primary hepatoma of the liver is here presented because of several points of interest: (1) the relative rarity of these conditions, and particularly the combination of the two in one patient, (2) the roentgen demonstration and correct interpretation of the findings, as confirmed at autopsy, (3) the racial and geographical significance of primary hepatic cancer. A 42-year-old corporal, a native of South America, was admitted to Winter General Hospital on Oct. 15, 1943, by transfer from a station hospital. He had entered the station hospital on Sept. 15, 1943, complaining of persistent dull epigastric pain. His appetite was good and there was no vomiting, although he had a sensation of obstruction in the stomach. There was no history of tarry or clay-colored stools. In 1938, the patient experienced an attack of severe epigastric pain which was relieved by a hypodermic injection. No diagnosis was made and he was comfortable up to the time of his admission, except for slight bloating lasting for a few minutes only. The blood findings, as determined at the station hospital, were: red cells, 4,200,000 and hemoglobin 89 per cent. Gastric analysis showed hyperchlorhydria. X-ray examination on Sept. 25 led to a diagnosis of possible diffuse gastric carcinoma or possible syphilis of the stomach. Since admission to the station hospital the patient had lost about twenty-five pounds in weight. He frequently had chills followed by elevation of temperature and profuse perspiration; he stated that he felt cold. Clinical Findings (Captain Magnes): On examination, on Oct. 16, 1943, at Winter General Hospital, the patient appeared pale and weak. He moved slowly in bed as if he were in pain. On breathing, the lower right chest and upper right abdomen showed splinting; the upper abdomen seemed slightly distended. The lungs and heart were normal. There was rigidity of the upper portion of the right rectus muscle on palpation, and below the xiphoid process on both sides a tender mass was palpable. This seemed more marked on the right and extended about 4 inches below the xiphoid process. The entire liver was enlarged about 2 inches below the costal margin. Laboratory Findings (Oct. 18): Red blood cells, 4,300,000; white blood cells, 10,000; hemoglobin, 13.8 gm. Occult blood in the feces, 3+. Total gastric acidity, 49.0; free hydrochloric acid, 45.0; no lactic acid. Van den Bergh test: direct, none; indirect, 0.47 mg. Urine negative. Roentgen Findings (Major Pomeranz): Radiographic and fluoroscopic study (Oct. 19) showed an orthotonic stomach of fair size, definite hypersecretion, good peristalsis throughout, and no defects. The duodenal cap showed no defects. The liver was enlarged. Fluoroscopic observation, in the prone right oblique position, showed a semicircular, faint linear extension of barium near the superior portion of the duodenum.