The Roentgen Diagnosis of Cholecystocolic Fistula

Abstract

IN 1925, Judd and Burden reviewed 153 cases of internal biliary fistulæ. Of this large group, only two were diagnosed pre-operatively by roentgenologic methods. In the last fifteen years roentgenologists have begun to meet this diagnostic challenge, and at the present time there are many reports of internal biliary fistulæ which were diagnosed pre-operatively with the aid of roentgenography. Internal biliary fistulæ have been reported to involve the gall bladder and almost every other organ in the abdomen and thorax. By far the majority of these fistulæ exist between the gall bladder and the duodenum. In distinction to the abundance of reports concerning the pre-operative diagnosis of cholecyst-duodenal fistula, there is a paucity of reports concerning the pre-operative roentgenologic findings in cholecystocolic fistula. In fact, in this country there have been reports of only five such instances (4, 7, 9, 13, 14). From the previous reports concerning this type of internal biliary fistula, certain criteria may be selected which are of aid in the diagnosis. These include (1) gas in the biliary tree, (2) non-visualization of the gall bladder after administration of dye, (3) demonstration by barium enema of the fistulous communication between the colon and gall bladder, and (4) mucous membrane changes in the colon at the site of the fistulous opening. Gas in the Biliary Tree.—From a theoretic standpoint the presence of gas in the biliary tree is usually assumed to be due to one of three things: (1) Reflux of gas through the ampulla of Vater; (2) the presence of gas-producing organisms in the gall bladder or gall-bladder wall, and (3) existence of an abnormal connection between the digestive system and the bile ducts or gall bladder. Sickels and Hudson reviewed 10 cases in which there was x-ray evidence of barium in the biliary tree (12). Extension of the barium through the ampulla of Vater was proved in five of these cases. Thus although barium has been observed in the biliary tree without the presence of a fistula, we have been unable to find any instance in which there is proof of reflux gas in the biliary duct system. In this connection we might add that a fistula between the gall bladder and any organ other than the digestive tract does not produce gas in the biliary tree. Such organisms as E. coli and C. Welchii have been found in about 50 per cent of surgically removed gall bladders (6), and two cases of gas bacillus infections of the gall bladder have been reported (11). It is important to know that in these patients there is no evidence of gas in the hepatic ducts. Among the somewhat similar lesions, Rigler has mentioned a patient in whom there was emphysema of the gall-bladder walls.