Unusual Case of Right Upper Quadrant Swelling

Abstract

Question: An 87-year-old woman presented to the emergency department with a 2-month history of pain and swelling over the right upper quadrant of her abdomen. She was otherwise fit and well. She was afebrile and hemodynamically stable. On examination, the abdomen was soft and nontender. A 5cm × 5cm tense, tender, fluctuant swelling with surrounding erythema was palpable in the right hypochondrium (Figure A,arrow). Full blood count, renal, and liver functions were within normal limits. She received an ultrasound of her abdomen which revealed the swelling to be in the subcutaneous plane. The abscess was subsequently incised and drained under local anaesthetic. She underwent a computed tomography scan (Figure B) of the abdomen, post drainage, due to the nature of contents in the abscess cavity. What is your diagnosis? Look on page 404 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Upon drainage of the abscess several multi-faceted gallstones discharged along with pus. There was, however, no bile or intestinal contents. Computed tomography scan of her abdomen revealed a fistulous tract between the fundus of the gallbladder and the anterior abdominal wall (Figure C). The gallbladder was also adherent to the anterior abdominal wall. She was comfortable after the procedure. Pus from wound swab was sterile. The patient admitted that she had suffered with intermittent right upper quadrant pain (biliary colic) several years previous to this. She did not have any further investigations as her symptoms had resolved spontaneously. Considering her age and lack of symptoms currently, she declined cholecystectomy and had an uneventful discharge from the hospital 2 days later. She was asymptomatic at 4-month follow-up. External biliary fistula is a rare complication of gallstone disease.1Nicholson T. Born M.W. Garber E. Spontaneous cholecystocutaneous fistula presenting in the gluteal region.J Clin Gastroenterol. 1999; 28: 276-277Crossref PubMed Scopus (27) Google Scholar Spontaneous cholecysto-cutaneous fistula is a rare phenomenon these days due to the universal availability of imaging for cholelithiasis and laparoscopic cholecystectomy.2Andley M. Biswas R.S. Ashok S. et al.Spontaneous cholecystocutaneous fistula secondary to calculous cholecystitis.Am J Gastroenterol. 1996; 91: 1656-1657PubMed Google Scholar, 3Henry C.L. ORT Jr, T.G. Spontaneous external biliary fistulas.Surgery. 1949; 26: 641-646PubMed Google Scholar The pathophysiology of this condition involves inflammation of the gallbladder leading to perforation of the gallbladder wall and fistula formation. The most common site for fistula is the right upper quadrant. However, fistulas have been reported in remote places such as the gluteal region.1Nicholson T. Born M.W. Garber E. Spontaneous cholecystocutaneous fistula presenting in the gluteal region.J Clin Gastroenterol. 1999; 28: 276-277Crossref PubMed Scopus (27) Google Scholar Various imaging modalities are helpful including ultrasound, fistulogram and computed tomography. In a young symptomatic patient this would warrant a cholecystectomy with complete excision of the fistulous tract.