Your Bile Ducts Are What You Eat: A Rare Etiology of Cholangitis Presidential Poster

Abstract

Introduction: Acute bacterial cholangitis is a dreaded complication of obstructed bile ducts, most commonly by gall stones (1). We report a rare cause of cholangitis, with an obstructed bile duct by food chyme from a choledocho-gastric fistula. Case Report: A 61 year old woman with cholecystectomy for chronic cholecystitis one month ago presented with right upper quadrant abdominal pain, darkened urine, and acutely elevated cholestatic liver tests with direct bilirubin level of 5.4 mg/dL. MRCP showed new intrahepatic and extrahepatic bile duct dilation with multiple intraductal hypointense structures and pneumobilia. During admission, patient developed worsening abdominal pain with sepsis. An urgent ERCP was performed for biliary decompression for presumed ascending cholangitis. Endoscopy revealed a pre-pyloric choledocho-gastric fistula. Cholangiogram via the fistula showed dilated common bile duct (1.5cm) with multiple filling defects. A biliary sphincterotomy was performed with drainage of pus, followed by balloon-sweep extraction of food chyme and placement of a 10mm x 6cm biliary metal stent. Patient had significant clinical improvement with resolution of her sepsis, abdominal pain, and elevated liver tests. 2 weeks later, patient had repeat ERCP for stent removal and biliary clearance. The persistent choledocho-gastric fistula was closed with an over-the-scope clip system (Bear-Claw). Discussion: Bilio-enteral fistulae are rare complications of cholecystitis with reported intra-op incidence of 0.15%-4.8% (2). The most common types of fistulae are cholecysto-duodenal, cholecysto-colonic, and choledocho-duodenal fistula (3). Choledocho-gastric fistula is a rare type of bilio-enteral fistulae, described only anecdotally. Definitive diagnosis often requires ERCP (4). For treatment, laparoscopic fistula closure using an endo-stapling device had been described during concurrent cholecystectomy (5). However, most often, endoscopic approach is taken that involves placement of a biliary stent to lower intra-ductal pressure and reduce flow through the fistula (6). The fistula typically resolves spontaneously within a few weeks, however sometimes requires endoscopic closure. Newer endoscopic techniques, utilizing overstitch endoscopic suturing system or over-the-scope clip system (our case), have been reported successful in closing the persistent fistula (7).Figure 1Figure 2