Cholecystogastric Fistula Research Articles

Холецистогастральный свищ. Мультидисциплинарный опыт диагностики и лечения редкого осложнения желчнокаменной болезни

Холецистогастральный свищ. Мультидисциплинарный опыт диагностики и лечения редкого осложнения желчнокаменной болезни

Surgical Management of Cholecystoenteric Fistula in Patients With and Without Gallstone Ileus: An Experience of 29 Cases.

BackgroundCholecystoenteric fistula (CEF) is an uncommon complication of cholelithiasis. Here, we report our experience on diagnostic methods and surgical management of CEF patients with and without gallstone ileus (GI).MethodsThis is a retrospective cases series over an 11-year period (2011–2022). Data analyzed included preoperative characteristics, ultrasound, imaging features, operation findings and postoperative course.ResultsA total of 29 patients diagnosed with CEF were enrolled, 51.7% (15/29) of whom were female, with a median age of 66 years (range: 35–96 years). With regards to subtype distribution, seventeen patients had cholecystoduodenal fistula (CDF), six had cholecystoconlonic fistula (CCF), three exhibited cholecystogastric fistula (CGF), one CDF combination with CCF and two CDF combination with type I Mirizzi syndrome. Twelve patients presented with gallstone ileus, and received one stage procedure or simple Enterolithotomy. The median operation time and blood loss of 157 min (range: 65–360 min) and 40 ml (range: 10–450 ml), respectively. Surgical complications, evidenced by fistula recurrence, were recorded in three patients (3/22; 13.6%), while four (4/29; 13.8%) and one patient (1/29; 3.4%) presented with wound infection and residual stone in common bile duct, respectively. No deaths were reported in our study.ConclusionCEF is a rare complication of gallstone disease that is occasionally found during operation. To date, no consensus has been reached regarding efficacious treatment therapies for CEF patients. For a CEF patient with GI, one stage procedure should be selected prudently, while simple Enterolithotomy would be a mainstream choice for relieving bowel obstruction.

Gallstone Ileus with Cholecystogastric Fistula in an Older Female

Cholecystogastric fistulas are a rare but life-threatening complication of cholelithiasis. This medical condition has been explained in detail in several cases in the medical literature. However, there is still conflicting debate on how well to effectively manage patients with such a complex medical condition. We present a 70-year-old Caucasian female with complaints of intermittent dull non-radiating abdominal pain. Her pain started abruptly after breakfast. Patient took some acetaminophen which alleviated her symptom. Several days later, pains return but at this time it was associated with constipation. Patient’s primary care physician (PCP) suspected peptic ulcer disease, which was quickly ruled out following negative result of Helicobacter pylori breath test. The PCP advised patient to visit the emergency department for further investigations to rule out/in possible gallstone ileus causing intestinal obstruction, or Bouveret’s syndrome.LEARNING POINTSNative triple-valve endocarditis is extremely rare, especially in the absence of predisposing conditions.Streptococcus gallolyticus has been associated with endocarditis as well colonic and hepatobiliary pathology, so gastrointestinal endoscopy is important as bacteraemia frequently precedes gastrointestinal symptoms, allowing prompt diagnosis.In multivalvular involvement, early surgery is often required, and timely recognition and treatment before complications develop may be decisive for prognosis.

Cholecystogastric fistula in Bouveret syndrome: Case report and literature review.

Introduction and importanceCholelithiasis is the benign bile pathology with major prevalence. A rare condition has been described, when a stone migrates through the duodenum causing small bowel obstruction (SBO), it's known as Bouveret syndrome, and it's attributed to almost 5% of SBO. Just 2% of the cases present with the migration of the stone through a fistula between gastric chamber and gallbladder, with limited reports in the literature.Clinical findingsWe present a case of an 87-year-old male with Bouveret syndrome and a cholecystogastric fistula with a stone in the gastric chamber who underwent laparoscopic gastrotomy to resolve the clinical case.ConclusionBouveret syndrome remains to be a rare condition in benign bile pathology. Individualized treatment should be performed and multidisciplinary approach leads to improved outcomes for the patient.

282 Cholecystoappendicular Fistula- 1st Ever Reported Case

Abstract A 30-year-old male presented with a history of recurrent episodes of acute cholecystitis; first acute attack associated with fever and nausea was 18 months prior to this presentation, for which he was managed conservatively for acute cholecystitis with antibiotics and analgesia following an ultrasound that showed features of acute cholecystitis with no obvious gallstones. The patient had further episodes of acute cholecystitis with no signs of obstructive jaundice and subsequent ultrasound showed multiple small gallstones. Due to the severity of his symptoms, he was scheduled for a planned cholecystectomy. During surgery (right subcostal incision)- findings were that of a contracted gall bladder with dense adhesions, after careful dissection a fistulous tract between the appendix and gallbladder was identified along with a cholecystoduodenal fistula. An en-bloc cholecystectomy plus appendicectomy was performed with the duodenotomy repaired. On the first day post op there was approximately 300 ml of bilious effluent in drain, a white cell count-8.1 x 109 and hemoglobin -12.1 g/dL, Serum bilirubin-1.4mg/dL, ALP-104mg/dL. The second and third post-operative days were uneventful with minimal bile mixed serous fluid in drain respectively with no other complains, following which the drains were removed and patient discharged home. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10–20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases. No case of cholecystoappendicular fistula has been reported so far.

S2325 Life-Threatening Gastrointestinal Hemorrhage as a Complication of a Cholecystogastric Fistula

S2325 Life-Threatening Gastrointestinal Hemorrhage as a Complication of a Cholecystogastric Fistula

Gallstone ileus associated with cholecystogastric fistula: Case report, diagnosis and surgical treatment.

IntroductionGallstone Ileus is a rare complication of cholelithiasis, associated with multiple episodes of cholecystitis, with the formation of adhesions and fistulas between the gallbladder and adjacent organs. Its diagnosis is difficult, requiring complementary imaging tests such as computed tomography or radiography.Presentation of caseFemale patient, with intestinal obstruction for 7 days, associated with abdominal pain and previous episodes of pain in the right hypochondrium for 3 months. Abdominal CT scan identified aerobilia, gallstone impacted in the ileocecal valve and small loop dilatation, in addition to a probable cholecystogastric fistula. Opted for exploratory laparotomy, enterolithotomy and fistula correction in one surgical time.DiscussionGallstone ileus is rare among the complications of cholelithiasis, in addition to the fact that cholecystogastric fistula is associated with gastric pylorus obstruction and not impaction on the ileocecal valve. Imaging tests are useful to complement the diagnosis, and if Rigler's triad is present, the suspicion of gallstone ileus is increased. The presence of fistula between the gallbladder and stomach presents a frequency between 0 and 13.3%. There is no gold standard treatment for gallstone ileus, but surgery options for each type of patient and severity level.ConclusionThere is no definitive protocol for optimal surgical treatment for biliary ileus, but the possibility of enterolithotomy associated with cholecystectomy and fistula correction can be evaluated in selected patients.

A Rare complication of Cholelithiasis: Cholecystocolic Fistula – Case Report

Although the pre-operative diagnosis of the cholecystocolic fistula has been reported, yet it is by no means a common finding. Cholecystocolic fistula is the second most type of biliary enteric fistula after cholecystoduodenal fistula. Cholecystogastric fistula is least commonly reported. We report our experience with cholecystocolic fistula discovered on imaging which was subsequently confirmed through surgery. The standard treatment for CCF is open cholecystectomy and closure of the fistula. Failure to identify preoperatively or intra-operatively can lead to various complications.

S2772 Bouveret Syndrome: Using Electrohydraulic Lithotripsy to Clear the Way

INTRODUCTION: Bouveret syndrome is a rare form of gallstone ileus that occurs by passage of a gallstone through an acquired cholecystoduodenal or cholecystogastric fistula into the enteric lumen leading to gastric outlet obstruction. It is seen in less than 0.5% of patients with cholelithiasis and represents 1-3% of all gallstone ileus cases. Although several cases of Bouveret Syndrome exist within the literature, we describe a rare case using electrohydraulic lithotripsy (EHL) as a successful treatment option. CASE DESCRIPTION/METHODS: A 67-year-old man with past medical history significant for metastatic melanoma and history of locally advanced tonsillar carcinoma presented to the hospital with acute onset nausea, vomiting, and abdominal pain for 2-day duration. On physical exam, he was afebrile and hemodynamically stable. His abdomen was mildly distended and tender without guarding. Lab assessment was unremarkable. An abdominal computed tomography (CT) revealed a cholecystoduodenal fistula and an obstructing calcified stone in the duodenum with pneumobilia (Figure 1). After a discussion with surgery, the patient was taken for an esophagogastroduodenoscopy (EGD) revealing a large, approximately 3 cm stone completely occluding the duodenal sweep (Figure 2). EHL under water immersion was used to break up the impacted stone. Small pieces were continuously removed from the duodenal lumen with a tripod grasper and placed in the stomach where they were further fragmented. Following gallstone clearance, a large ulcer and cholecystoduodenal fistulous tract was present in the duodenal sweep (Figure 3). The patient did well after the procedure and discharged home without complications. DISCUSSION: Being that Bouveret syndrome is rare and symptoms are nonspecific, a high clinical suspicion needs to exist to make an accurate diagnosis. Imaging findings suggestive of Bouveret syndrome include a dilated stomach, pneumobilia, and a radio-opaque shadow suggesting a gallstone. These findings make up Rigler's triad. Treatment options include surgery and endoscopic interventions. Multiple endoscopic modalities are utilized for the treatment of this syndrome including removal baskets, mechanical lithotripsy, electrohydraulic lithotripsy, and laser lithotripsy. EHL is commonly used, but only successful in 10 % of cases. Although reports of endoscopic success are poor in the literature it should be attempted to decrease the morbidity and mortality associated with surgery that can be as high as 25%.Figure 1Figure 2Figure 3

S2791 Bouveret Syndrome: An Unusual Cause of Gastric Outlet Obstruction (GOO)

INTRODUCTION: Bouveret syndrome is an extremely rare clinical condition caused by gallstone ileus due to cholecystoduodenal or cholecystogastric fistula in the setting of cholecystitis. The impacted gallstone in the duodenum causes gastric outlet obstruction, manifesting as epigastric pain, nausea, and vomiting. Owing to its scarcity of reported cases, diagnosing and treating this syndrome is challenging. Our case report emphasizes the early recognition of a clinical syndrome, which should suggest Bouveret syndrome rather than other causes of gastric outlet obstruction, such as malignancy. CASE DESCRIPTION/METHODS: A 68-year-old female with a past medical history of cholelithiasis and hypothyroidism presented with a 2-day history of epigastric pain. The pain was located in the epigastric region, associated with nausea and vomiting. Labs were non-significant except for mild leukocytosis. CT revealed numerous gallstones with gallbladder wall thickening, along with markedly dilated stomach with pyloric wall thickening showing partial gastric outlet obstruction (GOO) (Figure 1). RUQ ultrasonogram showed WES sign and DISIDA scan showed cystic duct obstruction, CT guided biopsy was done at GB wall and pylorus but was negative for malignancy. EGD showed high-grade pyloric stricture causing a GOO for which NG tube was placed. TPN was initiated and EGD was reattempted on hospital day 9, which showed a small fistulous opening in the gastric antrum along with a gallstone partially filling the duodenal bulb. The gallstone was noted to “ball-valve” in the area with insufflation and suction via the scope. The findings were consistent with Bouveret syndrome, which was corroborated on MRCP (Figure 2). The patient underwent open partial cholecystectomy, repair of cholecystoduodenal fistula, gastrojejunostomy, and enterolithotomy on hospital day 14. Post-operatively, the patient had delayed recovery of gastric function and required prolonged nasogastric tube placement. The recovery was also complicated by Bacteroides Fragilis bacteremia. The patient was eventually discharged on hospital day 29. DISCUSSION: Calculous cholecystitis with gastric outlet obstruction is a clinical situation, which Bouveret syndrome should be considered strongly. Since the majority of patients are old and have other comorbid conditions, the mortality rate is higher than those with other causes of mechanical small bowel obstruction. Maintaining a high level of suspicion can avoid delay in the diagnosis and can lead to timely surgical interventions.Figure 1.: Gallstones filling the gallbladder with wall thickening and pericholecystic fluid. Markedly distended stomach with pyloric wall thickening concerning for GOO.Figure 2.: Cholecystitis with findings suspicious for a cholecystoduodenal fistula and 2.9cm gallstone in the region of the first portion of duodenum, suggestive of Bouverete syndrome.

Innovation of EUS-guided transmural gallbladder drainage using a novel self-expanding metal stent

Endoscopic ultrasonography (EUS)-guided transmural drainage has been accepted as a modality of choice in peripancreatic fluid collection and acute cholecystitis. Each type of stent, including double-pigtail plastic stents, tubular self-expandable metal stents (SEMS), and lumen-apposing metal stents, for these procedure has its own advantages and disadvantages. To overcome their disadvantages, this animal study evaluated the feasibility of a newly designed twisted fully covered SEMS with spiral coiled ends. We performed the EUS-guided cholecystogastrostomy with a newly developed metal stent in eight mini pigs with surgically induced gallbladder distension. This novel stent is a twisted fully covered SEMS with spiral coiled ends, a diameter of 8 mm, and a length of 6 cm. The stent has been maintained for four to seven weeks after EUS-guided cholecystogastrostomy. The primary outcome was the technical success rate, and the secondary outcomes were adverse events, stent dysfunction, stent removability, and fistula formation. The stent was placed successfully between the gallbladder and the stomach in all cases without any adverse event. We observed neither stent migration nor dysfunction during the study period, and all the stents were removed easily as scheduled. We confirmed successful cholecysto-gastric fistula formation at endoscopic and histologic level in all cases. EUS-guided transmural drainage and fistula formation using a new twisted fully covered metal stent with spiral coiled ends was technically feasible without any adverse event in this animal study. Further clinical studies are needed to evaluate its efficacy and safety in real practice.

Spontaneous cholecystogastric fistula treated endoscopically

Spontaneous cholecystogastric fistula treated endoscopically

Su1314 INNOVATION OF EUS-GUIDED TRANSMURAL GALLBLADDER DRAINAGE USING A NOVEL SELF-EXPANDING METAL STENT

Endoscopic ultrasonography (EUS)-guided transmural drainage has been accepted as a modality of choice in peripancreatic fluid collection and acute cholecystitis. Each type of stent, including double-pigtail plastic stents, tubular self-expandable metal stents (SEMS), and lumen-apposing metal stents, for these procedure has its own advantages and disadvantages. To overcome their disadvantages, this animal study evaluated the feasibility of a newly designed twisted fully covered SEMS with spiral coiled ends. We performed the EUS-guided cholecystogastrostomy with a newly developed metal stent in eight mini pigs with surgically induced gallbladder distension. This novel stent is a twisted fully covered SEMS with spiral coiled ends, a diameter of 8 mm, and a length of 6 cm. The stent has been maintained for four to seven weeks after EUS-guided cholecystogastrostomy. The primary outcome was the technical success rate, and the secondary outcomes were adverse events, stent dysfunction, stent removability, and fistula formation. The stent was placed successfully between the gallbladder and the stomach in all cases without any adverse event. We observed neither stent migration nor dysfunction during the study period, and all the stents were removed easily as scheduled. We confirmed successful cholecysto-gastric fistula formation at endoscopic and histologic level in all cases. EUS-guided transmural drainage and fistula formation using a new twisted fully covered metal stent with spiral coiled ends was technically feasible without any adverse event in this animal study. Further clinical studies are needed to evaluate its efficacy and safety in real practice.

Liver Abscess Caused by Citrobacter Freundii Secondary to Cholecysto-antral Fistula: A Case Report

Liver abscesses secondary to bilio-enteric fistulas are rare and therefore unknown to the attending physician. In this report, we present a bilio-enteric communication, between the gallbladder; which was macro lithiasic; and the stomach revealed by an upper digestive hemorrhage in a septic context in a 34 year old man. A pyogenic bacterial liver abscess developed because of the fistula without biliary obstruction. The patient was treated surgically with disconnection of the fistula and drainage of the abscess. The liver abscess is probably due to the contamination of the bile by the cholecysto-gastric fistula. The germ isolated was a citrobacter freundii which is rarely involved in liver abscesses.

Bouveret’s syndrome and cholecystogastric fistula: a case-report and review of the literature

An exceptionally rare cause of gastric outlet obstruction, Bouveret's syndrome results from proximal impaction of an ectopic gallstone, enabled by fistulization that aberrantly connects the biliary and luminal gastrointestinal tract, typically a cholecystoduodenal fistula. It occurs with a 2:1 female predominance, most often in the eighth decade of life. Endoscopic treatment is the preferred first-line strategy in management, followed by surgical intervention if unsuccessful. Endoscopy failed to retrieve the stone due to its size, despite attempted lithotripsy, which prompted laparoscopic retrieval. Bouveret's syndrome compels a high index of suspicion in proximal gastrointestinal obstruction even when presenting in a male a decade younger than the median age of diagnosis (74years), with no preceding biliary symptoms particularly as early intervention can considerably reduce morbidity and mortality.

Bouveret's syndrome and biliary ileus. An extremely rare cause of gastric obstruction

Blackground: Bouveret’s syndrome and biliary ileus, an extremely rare cause of gastric obstruction (about 300 cases published about Bouveret’s syndrome), is due to the impaction of a duodenal calculus secondary to a cholecystoduodenal or cholecystogastric fistula. It is associated with women, with more than 70 years old and large gallstones. The surgical treatment depends of the patient, the side of the calculus and its location. Surgical treatment is enterolithotomy with or without cholecystectomy. The fistula can close spontaneously so its repair may be unnecessary. The aim is to present two cases of biliary ileus and we do a bibliographic review to know its management. Material & Methods: The first patient was an 81 years old male who consulted in the emergency room for oral intolerance and vomiting. A CT study was performed, finding a cholecystoduodenal fistula and lithiasis that causes intestinal obstruction in the duodenum (figure 1). The other patient, was an 91 years old female who consulted in the emergency room for vomiting. In CT we could see a cholecystoduodenal fistula and a lithiasis in ileon that caused intestinal obstruction. Results: First patient underwent surgery with enterolithotomy. Six days after surgery, the patient was discharged home without symptoms. In the second case, the patient needed surgery with enterolithtomy, cholecystectomy and closure of the duodenum. In Conclusion: in these patients, intestinal obstruction must be treated first with an enterolithotomy and a biliary procedure, including cholecystectomy and biliary-enteric fistula closure, in low-risk patients.

CHOLECYSTOGASTRIC FISTULA: A RARE COMPLICATION OF CHOLELITHIASIS/ASCENDING CHOLANGITIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Cholecystogastric fistula is an abnormal connection between bile duct and stomach. It is a rare complication of long term cholelithiasis, cholecystitis and cholangitis. We describe an interesting case of this rare presentation in a 97-year-old male presenting with abdominal pain and vomiting. CASE PRESENTATION: A 97-year-old male with multiple comorbidities was admitted with vomiting, abdominal pain and distention. Surgical history was remarkable for choledocholithiasis complicated by ascending cholangitis for which he had undergone ERCP with sphincterotomy and stone removal. Vital signs were stable but physical exam was remarkable for a distended, non-tender abdomen with voluntary guarding on deep palpation. Laboratory investigations showed a serum creatinine of 2.2 mg/dL (baseline 1.5-1.7). Other laboratory investigations and infectious workup including blood/urine cultures and hepatitis profile were negative. Abdominal film showed persistent dilated small bowel loops suggestive of diffuse small bowel ileus or obstruction. Ultrasound of abdomen showed gallstones and dilated common bile duct (CBD) with air in the biliary tree. Further imaging with CT/MRI abdomen revealed a fistulous communication between the gastric antrum and the gallbladder/CBD. The patient was managed conservatively given his age and multiple comorbidities. DISCUSSION: Enteral fistulae are abnormal connections resulting from chronic inflammation between tightly adherent walls. They can be congenital or acquired, internal or external. Cholecystoenteric fistulae are of three types: (I) cholecystogastric, (II) cholecystoduodenal, and (III) cholecystocolonic. The rarest among the three are cholecystogastric fistulae and they are associated with significant morbidity and mortality. Underlying etiologies include cholecystitis, cholangitis, trauma, inflammatory bowel disease, peptic ulcer disease and gastrointestinal tract malignancies. Outcomes can vary from clinically silent fistulas to gall stone ileus, cholangitis, peritonitis or gastrointestinal hemorrhage. Abdominal film, ultrasonography, barium studies and CT are most common used modalities for diagnosis. Percutaneous transhepatic cholangiography, ERCP or magnetic resonance cholangiopancreatography can give more specific details but are more invasive and hence were not appropriate for our patient. Treatment is mostly surgical either open, laparoscopic or endoscopic. Our patient had significant co-morbidities and poor functional status and therefore had to be managed conservatively. CONCLUSIONS: This case brings to light a relatively rare complication of cholelithiasis and cholangitis. Reference #1: Cholecystogastric fistula: a brief report and review of the literature. Boland MR, Bass GA, Robertson I, Walsh TN. J Surg Case Rep. 2013 Apr 24;2013(4). pii: rjt028. https://doi.org/10.1093/jscr/rjt028. Reference #2: Laparoscopic management of cholecystoenteric fistula: A single-center experience. Li XY, Zhao X, Zheng P, Kao XM, Xiang XS, Ji W. J Int Med Res. 2017 Jun;45(3):1090-1097. https://doi.org/10.1177/0300060517699038. Epub 2017 Apr 18. Reference #3: Pneumobilia: a case report and literature review on its surgical approaches. Wong CS, Crotty JM, Naqvi SA. J Surg Tech Case Rep. 2013 Jan;5(1):27-31. https://doi.org/10.4103/2006-8808.118616. DISCLOSURES: No relevant relationships by Moses Bachan, source=Web Response No relevant relationships by Muneer Khan, source=Web Response No relevant relationships by Zinobia Khan, source=Web Response No relevant relationships by Mariam Saeed, source=Web Response

1268 The Hidden Gallbladder: An Unusual Case of Bouveret Syndrome

INTRODUCTION: Bouveret syndrome is the most infrequent variant of gallstone ileus characterized by a biliary fistula with the stomach or small intestine. The fistula occurs from recurrent gallbladder inflammation causing adhesion to the GI tract followed by local necrosis. Patients generally present nausea, vomiting, and abdominal pain/distention with variable lab abnormalities, with jaundice and hepatic enzyme alternations in only 1/3 of patients. 43-68% of patients have a history of recurrent biliary colic and given the delay in diagnosis, patients can present very late with dehydration and weight loss. CT scan is diagnostic modality of choice with an overall 93% sensitivity, 100% specificity, and 99% diagnostic accuracy. We present a rare case of Bouveret Syndrome missed by CT scan and diagnosed by ERCP. CASE DESCRIPTION/METHODS: Our patient is an 81-year-old male who presented with jaundice and intermittent fever/chills. He reported 7 months of intermittent nausea, vomiting, and abdominal pain and reportedly lost approximately 80 pounds in the past year. The patient denied any prior cholecystectomy. He was noted to have total bilirubin of 8.1 and an alkaline phosphatase of 523. RUQ U/S showed a 1.5 cm common bile duct (CBD) and non-visualization of the gall bladder. CT scan was performed showing CBD of 2.0 cm but no clear cholelithiasis and reported absence of the gallbladder. Patient subsequently had EUS/ERCP. EUS showed a shrunken decompressed gallbladder with cholelithiasis (Figure 1) and bilious output into the lesser curvature of the stomach concerning for fistulous process. ERCP showed dilated CBD with multiple large gallstones with sphincterotomy and balloon extraction (Figure 2). Impaction cholangiogram with cinematic fluoroscopy confirmed a cholecystogastric fistula (Figure 3). The patient was a poor surgical candidate but had improvement in his symptoms and liver function tests and was safely discharged home. DISCUSSION: Bouveret syndrome is a very rare complication of gallstone ileus that can have high mortality due to its late and nonspecific presentation. There have been approximately 300 cases of documented Bouveret syndrome with 60% of cases involving a cholecystoduodenal fistula. 5% of cases present with a cholecystogastric fistula. As CT is the mainstay of diagnosis, our case is further unique in that CT scan and RUQ U/S reported an absent gallbladder (which the patient denied), likely due to the contracted nature noted on EUS and required endoscopic visualization and ERCP to confirm.

1349 A Rare Presentation of Cholecystogastric Fistula With Associated Mirizzi Syndrome Leading to the Diagnosis of Gallbladder Cancer

INTRODUCTION: Biliary fistulas are a rare complication of gallstone disease. Technological advances have allowed for successful management & diagnosis. Mirizzi syndrome is a condition seen in less than 1% of patients with cholelithiasis & malignancy in 5 to 28% of cases. This is a rare presentation of coexistent Mirizzi syndrome and a cholecystogastric fistula leading to the diagnosis of gallbladder adenocarcinoma. CASE DESCRIPTION/METHODS: A 68 y/o female presented to the ER with complaints of jaundice & pruritis. Records demonstrated prior CTA&P with cholelithiasis with stranding & nonspecific stranding around the distal stomach. MRI w/wo contrast demonstrated loss of fat plane between gallbladder & stomach suggestive of fistulizing disease & a filling defect within the extrahepatic common hepatic duct related to external compression suggestive of Mirizzi Syndrome, no pneumobilia was seen. EGD/EUS was without direct visualization a fistulous tract, but revealed ulceration of gastric mucosa suggesting extrinsic pressure from a gallstone. ERCP demonstrated a stricture within the proximal CBD. Brushings were negative for malignancy. Lap chole revealed adherence of the stomach to the gallbladder fundus & takedown of cholecystogastric fistula was also performed. Histology from gallbladder specimen returned positive for invasive poorly-differentiated adenocarcinoma with transmural and lymphatic invasion. DISCUSSION: The presentation of cholecystogastric fistula generally includes pneumobilia & lacks pruritis suggestive of obstructive jaundice due to drainage of the biliary system via tract formation. Yet during the development of the fistulous tract the presentation varies quite drastically. Surgery is guided by the sub-classification of fistula formation/erosion as noted in the table figure. ERCP allows better characterization of the anatomy, in addition to offering the potential for therapeutic intervention with biliary decompression. There is an important known relationship between Mirizzi syndrome & gallbladder cancer likely related to the recurrent irritation occurring in the region along with chronic biliary stasis therefore frozen sections should be performed in all cases of Mirizzi syndrome to conclusively evaluate for gallbladder cancer. Our case highlights the malignancy potential within the presentation of fistulizing gallbladder disease. With a heightened index of suspicion and advancements in endoscopic and surgical techniques management of these patients will hopefully become less challenging.

1453 Cholecystocolic Fistula: An Unusual Cause of Abdominal Pain

INTRODUCTION: Biliary-enteric fistula is a rare but a pertinent complication of gallbladder disease. It is usually a complication of acute cholecystitis. It occurs in 0.06%-0.14% of patients with biliary disease. Cholecystoduodenal (70%) is the most common site of communication of the fistula, followed by cholecystocolic (10-20%), and then cholecystogastric fistula (10-20%). Failure to identify these fistulas during cholecystectomy can have catastrophic complications as it may result in division of the fistula, perforation of the colon that can result in fecal peritonitis which ultimately can lead to sepsis and death. We are reporting a 57-year-old female presenting with diffuse sharp abdominal pain, nausea, vomiting who was found to have a cholecystocolic fistula and a 1.7 cm gallstone in the proximal sigmoid colon. CASE DESCRIPTION/METHODS: A 57-year-old Caucasian Female with a history of diverticulosis presented with diffuse sharp worsening abdominal pain, nausea, vomiting and diarrhea. Her physical exam was normal except for diffuse abdominal tenderness. Her Laboratory findings were unremarkable including her liver function tests. An abdominal CT scan showed a non obstructing 1.7 cm gallstone in the proximal sigmoid colon and a fistula between the hepatic flexure and the gallbladder (Figures 1 and 2). It also showed evidence of colitis in in the distal left colon and proximal sigmoid colon. Patient was scheduled for a cholecystectomy with fistula repair. DISCUSSION: Cholecystocolic fistula is a rare but a pertinent complication of gallbladder disease. Although a diagnosis of cholecystocolic fistula is rarely suspected clinically, Clinicians should be aware of it given that it can have catastrophic complications.