Choledochoduodenal Fistula Research Articles

Endoscopic closure of large, spontaneous, choledochoduodenal fistula by using an over-the-scope clip

Endoscopic closure of large, spontaneous, choledochoduodenal fistula by using an over-the-scope clip

Endoscopic Ultrasonography-Guided Biliary Drainage: Evaluation of a Choledochoduodenostomy Technique

Background: Endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (CDS) is as an alternative to percutaneous transhepatic biliary drainage (PTBD) in patients with biliary obstruction when endoscopic retrograde biliary drainage (ERBD) is unsuccessful. Purpose: We reviewed our experience and technique in patients undergoing EUS-CDS. Patients: Over a 2-year period to December 2008, 15 patients with unsuccessful ERBD underwent EUS-CDS. Methods: EUS-guided needle puncture was performed to access the bile duct from the duodenal bulb. After cholangiography, a guidewire was inserted through the needle and directed to the hepatic hilum. The punctured fistula was then dilated with a biliary dilator and a plastic stent was inserted. Results: The technical success rate of EUS-CDS was 93% (14/15 patients); 1 patient underwent an EUS-guided rendezvous approach because the choledochoduodenal fistula could not be dilated. Decompression of the bile duct was achieved in all patients. Complications included cholangitis in 4 patients, self-limiting local peritonitis in 2 and distal stent migration in 1 patient. The median follow-up time was 125 days and the median duration of stent patency was 99 days. Conclusion: EUS-CDS may be effective for patients following unsuccessful ERBD and offers an attractive alternative to PTBD.

Diagnosis and Management of Choledochoduodenal Fistula

Recent advances in hepatobiliary imaging techniques have led to the increased detection of choledochoduodenal fistula. However, the diagnosis and treatment of choledochoduodenal fistula is still a challenge. In this study, we summarize how patients were diagnosed and treated for choledochoduodenal fistula at our institution. Sixty-six patients with choledochoduodenal fistula were diagnosed and treated in our department from January 2000 to June 2009. Sixty-one patients were treated operatively, whereas five patients were treated with medicine. Patients with choledochoduodenal fistula were confirmed by endoscopic retrograde cholangiography. Of the 61 patients needing surgical intervention, clinical outcomes were excellent in 57 patients, and five patients underwent successful laparoscopic surgery for repairing the choledochoduodenal fistula. Follow-up of these patients for 6 months to 10 years showed they did not suffer from further cholangitis. A patients' past history of biliary disease, upper abdominal pain, fever, and jaundice may lead to choledochoduodenal fistula. Operative therapy, including laparoscopic surgery, was the primary treatment for most patients, regardless of the preoperative diagnosis.

Extra-hepatic biliary injury secondary to blunt abdominal trauma: A successful management strategy

Extra-hepatic bile duct injury from blunt abdominal trauma is uncommon. Complete traumatic transection of the common bile duct (CBD) with subsequent complication of a choledochoduodenal fistula is extremely rare and only a handful of reports are found in the medical literature. We describe a 20-year-old male patient who presented with a complete transection of the CBD following blunt abdominal trauma and his subsequent planned staged management.

Bouveretʼs Syndrome

Purpose: Case: An 82-year-old female with a history of coronary artery disease presented with 4 days of nausea, bilious vomiting, and epigastric pain radiating to left scapula. On exam she was afebrile, BP 157/64 mmHg with abdominal distention, epigastric tenderness, tympanic on percussion and decreased bowel sounds. The laboratory results include Cr 3.2 mg/dl, BUN 30 mg/dl, alkaline phosphatase 146 IU/L, ALT 19 IU/L, AST 23 IU/L, total bilirubin 1.0 mg/dl, amylase 710 IU/L, lipase 133 Units/L and WBC of 6200 cells/cu.ml. CT scan of abdomen (Figure 1) showed pneumobilia, choledochoduodenal fistula (CBD and 2nd part of duodenum) and a large 3.6 cm gallstone obstructing the distal duodenum. This was consistent with gallstone ileus. The upper GI endoscopy confirmed the impacted gallstone, which could not be extracted endoscopically. The patient underwent jejunal enterolithotomy for gallstone removal and right hemicolectomy with ileotransverse colon anastamosis for ischemic ascending colon found intraoperatively. The postoperative course was complicated by NSTEMI, pulmonary edema requiring mechanical ventilation, bacillus bacteremia and DIC manifesting as hemoperitoneum. Over the course of hospital stay, bilirubin trended upto 35 mg/dl (direct bilirubin -19.8 mg/dl), INR to 2.6, AST 203 IU/L, ALT 65 IU/L on post op day 22 but Alkaline phosphatase was normal. Abdominal USG did not show any biliary dilatation. The patient died 22 days after surgery secondary to cardiac arrest. Discussion: Bouveret's syndrome is a rare variant of gallstone ileus caused by the migration of the large biliary calculus [>2 cm] through cholecystoduodenal or choledochoduodenal fistula resulting in duodenal obstruction. The characteristic radiographic picture is the Rigler's triad of bowel obstruction, pneumobilia and a gallstone in small bowel. Upper GI endoscopy is diagnostic in 69% of cases. If the endoscopic removal fails, the most common surgical therapy is enterolithotomy with or without cholecystectomy and fistula repair. Other options include extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy or mechanical lithotripsy.Figure

SUCCESSFUL ENDOSCOPIC EXTRACTION OF A LARGE IMPACTED CHOLEDOCHOLITHIASIS IN THE AMPULLA OF VATER: TWO INTERESTING CASES

In patients with choledocholithiasis, a stone can sometimes become impacted in the ampulla of Vater, potentially resulting in the complications of acute cholangitis and acute pancreatitis. Endoscopic sphincterotomy and needle knife papillotomy are very effective for the removal of an impacted stone in the ampulla of Vater. Dramatic improvement of the symptoms may be expected if these procedures are performed sufficiently early after the occurrence of the impaction. However, depending on the size, site and situation of the impacted stone, we have often encountered difficulties during endoscopic treatment. We encountered two interesting cases of choledocholithiasis with impaction of large stones in the ampulla of Vater. In Case 1, treatment with radial incisions was added to the usual treatment of needle knife papillotomy, because of the large size of the stone, and the combined treatment was effective. In Case 2, a large periampullary choledochoduodenal fistula was created at the ampulla of Vater, and an indwelling double pigtail tube was placed in the ampulla; the stone then discharged via the tube without additional need for endoscopic sphincterotomy or needle knife papillotomy. Our experience in these cases indicates that innovations in treatment according to the situation of the impacted stone may be needed for the treatment of giant impacted stones in the ampulla of Vater.

ERCP in Patients With Sickle Cell Disease: Diagnostic and Therapeutic Dilemmas.

BackgroundCholestatic jaundice (CJ) in patients with sickle cell disease (SCD) poses diagnostic and therapeutic dilemmas. This is an evaluation of the role of ERCP in SCD.MethodsA total of 224 SCD patients with CJ had ERCP. The indications for ERCP were based on clinical and biochemical evidence of CJ and ultrasound findings.ResultsThe indications were: CJ only in79, CJ and dilated ducts in 103, and CJ and biliary stones in 42. The ERCP findings were: (A) For those with CJ only: ERCP was normal in 45, showed dilated ducts with no stones in 13, dilated ducts with stones in 16, normal CBD with a stone in 1; (B) For those with CJ, dilated ducts: ERCP was normal in 17, showed dilated ducts with stones in 47, dilated ducts without stones in 28, normal CBD with a stone in 1, a choledochoduodenal fistula in 2; (C) For those with CJ and duct stones: ERCP was normal in 2, showed dilated ducts with stones in 21, dilated ducts without stones in 14, normal CBD with a stone in 1.ConclusionsERCP was unnecessary in a significant number (27%) of patients. This is especially so for those with CJ only (57%). These should be evaluated further prior to ERCP. There was also a significant number (19%) who had ES for duct dilatation without an obstruction. The reason for this dilatation is not known and the value of ES in this group needs to be investigated further.

Choledochoduodenal fistula of ulcer etiology

Choledochoduodenal fistulas are very rare and in most cases are caused by a long-lasting and poorly treated chronic duodenal ulcer. They may be asymptomatic or followed by symptoms of ulcer disease, by attacks of cholangitis or bleeding or vomiting in cases of ductoduodenal stenosis. The diagnosis is simple and safe, however treatment is still controversial. If surgery is the choice of treatment, local findings should be taken into consideration. As a rule, intervention involving closure of fistula is not recommended. The authors present a 60-year-old woman with a long history of ulcer disease who developed attacks of cholangitis over the last three years. Ultrasonography and CT showed masive pneumobilia due to a choledochoduodenal fistula. As there was no duodenal stenosis or bleeding, at operation the common bile duct was transected and end-to-side choledochojejunostomy was performed using a Roux-en Y jejunal limb. From the common bile duct, multiple foreign bodies of herbal origin causing biliary obstruction and cholangitis were removed. After uneventful recovery the patient stayed symptom free for four years now. The performed operation was a simple and good surgical solution which resulted in complication-free and rapid recovery with a long-term good outcome.

Spontaneous Choledochoduodenal Fistula after Metallic Biliary Stent Placement in a Patient with Ampulla of Vater Carcinoma

Biliary stent-related enteric perforations are very rare complications that are caused by the sharp end of a metallic stent, stent migration, or tumor invasion. Moreover, the choledochoduodenal fistula resulting from metallic biliary stent-induced perforation is extremely rare. Here, we report a case in which a spontaneous choledochoduodenal fistula occurred after biliary metallic stent placement in a patient with an Ampulla of Vater carcinoma but was successfully managed by supportive treatments, including nasobiliary drainage. This case might have occurred as the result of a rupture of the bile duct following pressure necrosis and inflammation caused by impacted calculi and food materials over the tumor ingrowth in the uncovered biliary stent.

Choledochoduodenal fistula caused by cholangiocarcinoma of the distal common bile duct

Choledochoduodenal fistula caused by cholangiocarcinoma of the distal common bile duct

Roux-en-Y Duodenojejunostomy in the Treatment of Bouveret Syndrome

Bouveret syndrome is a rare complication of cholelithiasis occurring when a gallstone passes through a cholecystoduodenal or choledochoduodenal fistula and lodges in the pylorus or proximal duodenum causing a gastric outlet obstruction. The case of a 70-year-old male who developed Bouveret syndrome is presented, and the management of this presentation of gallstone ileus by Roux-en-Y duodenojejunostomy is discussed in detail.

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY FOR PALLIATIVE BILIARY DRAINAGE IN CASES WITH INOPERABLE PANCREAS HEAD CARCINOMA

Endoscopic transpapillary biliary drainage (EBD) or stenting is the gold standard treatment for inoperable malignant biliary obstruction. When the papilla cannot be traversed because of pyloric or duodenal stenosis, or the catheter cannot be introduced, or because of previous surgery, the usual alternative method is considered to be percutaneous transhepatic biliary drainage (PTBD). We herein report our experiences with four cases with inoperable pancreatic head carcinoma associated with obstructive jaundice treated by endoscopic ultrasonography-guided biliary drainage (EUS-BD). Between September 2006 and December 2007, methods of EUS-BD were performed in four cases with inoperable pancreas head carcinoma. In three out of four cases, EBD and PTBD were unsuccessful because of previous surgery, or duodenal stenosis, or nondilated intrahepatic bile ducts. In one case, although PTBD was successful, internal drainage could not be established. EUS-BD was successful for all cases. The obstructed biliary system was successfully decompressed by the creation of a choledochoduodenal fistula and the insertion of a transduodenal biliary plastic stent. No complication was encountered in all cases. EUS-BD may have the potential of replacing PTBD in cases with inoperable pancreatic head carcinoma associated with obstructive jaundice.

Recurrent acute pancreatitis caused by intra-ampullary carcinoid tumor

View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image A 59-year-old nurse with a history of cholecystectomy for cholelithiasis and 2 episodes of moderate abdominal pain associated with nausea 3 months previously was referred to our department for ERCP; 2 isolated serum pancreatic amylase values were 795 and 820 IU/L (normal <30 IU/L). MRCP demonstrated dilation of the pancreatic duct but not of the common bile duct. ERCP revealed an enlarged yellowish ampulla and a bit of pale tissue protruding from the papillary orifice (A). Moreover, a small choledochoduodenal fistula was observed in the base of the papilla, explaining why the common bile duct was not dilated. Endoscopic sphincterotomy opened the ampulla and revealed a small polypoid tumor (B). The tumor was inadvertently sectioned by the sphincterotome, causing bleeding that was easily stopped by injection of 4 mL of adrenaline solution (1:10,000). The tumor was collected with a small Roth net, and histologic evaluation showed a nest of neuroendocrine cells (C, H&E orig. mag. ×40). Chromogranin (D, orig. mag. ×40) and synaptophysin (E, orig. mag. ×40) stains confirmed the diagnosis. All margins were negative for tumor infiltration. EUS, performed 1 month later, revealed no residual tumor or ductal obstruction. The patient recovered uneventfully and remained well for the next 4 months. View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image View Large Image Figure Viewer Download Hi-res image

Resource Rent in Individual Quota Fisheries

Pneumobilia is the finding of air in the biliary tree. Most cases are iatrogenic in origin, especially after sphincterotomy and after hepaticojejunostomy or choledochojejunostomy. In patients without such history, the presence of pneumobilia needs further investigation. Most patients are likely to have an enterobiliary fistula. Although patients may be asymptomatic, possible complications include gallstone ileus, Bouveret syndrome or recurrent episodes of cholangitis. We present a case of a 38-year-old man presenting with obstructive jaundice and pneumobilia in whom choledochoduodenal fistula was diagnosed at endoscopic retrograde cholangiography. A description of different types of choledochoduodenal fistulas and management recommendations are also provided.

Choledochoduodenal fistula caused by blunt abdominal trauma in a child

We report a 15-year boy who presented with obstructive cholangiopathy and pancreatitis after blunt abdominal trauma. A magnetic resonance cholangiopancreatography showed dilated common bile duct, dilated hepatic ducts, and a suspicious choledochoduodenal fistula. An endoscopic retrograde cholangiopancreatography revealed a parapapillary choledochoduodenal fistula. An operation of choledochojejunostomy, excision of common bile duct, and cholecystectomy was done for recurrent cholangitis. Abdominal symptoms completely subsided one month later. Serum amylase, lipase and bilirubin levels turned to normal 3 months after operation.

Recurrent Gallstone Ileus

We report herein the case of a 57-year-old man who presented after the third occurrence of gallstone ileus. The patient underwent successful enterolithotomy, partial cholecystectomy, and repair of choledochoduodenal fistula. Although recurrent gallstone ileus is relatively rare, its occurrence is an indication for definitive management of the biliary-enteric fistula.

EUS-guided choledochoduodenostomy for palliative biliary drainage in patients with malignant biliary obstruction: Results of long-term follow-up

Five patients with obstructive jaundice caused by malignant periampullary biliary stenosis underwent EUS-guided choledochoduodenostomy (EUS-CDS) from the first portion of the duodenum using a convex echoendoscope and a needle knife. All the steps of the procedure including passage dilatation and the plastic stent placement were performed through the accessory channel of the echoendoscope over the guide wire. Stent insertion was technically successful in all five patients. The procedure was also clinically effective in relieving jaundice in all cases. One patient developed pneumoperitoneum, which resolved with conservative management. Stent exchange was successful in seven of eight attempts in patients with stent occlusion. One failure was due to tumor invasion to the choledochoduodenal fistula. Stent patency was maintained in the remaining patients throughout their survival period. The average stent patency was 211.8 days. EUS-CDS from the first portion of the duodenum appears to be feasible and safe in cases of obstructive jaundice caused by distal bile duct obstruction.

Duodenal ulcer with choledochoduodenal fistula presenting acutely with free perforation into the peritoneal cavity

BACKGROUND: Choledochoduodenal fistulae are rare and are usually diagnosed incidentally on the investigation for upper gastrointestinal symptoms. It is unusual for them to present as an emergency with free perforation into the peritoneal cavity. METHOD: Case report. RESULTS: Described below is a case report of a 68-year-old man who, after a short history of epigastric pain, presented as an emergency with the symptoms and signs of peritonitis and was found at laparotomy to have a perforated duodenal ulcer eroding into the common bile duct with free bile leakage. The operative procedure performed fulfilled the criterion for the surgical management of choledochoduodenal fistulae described by Hutchins nearly half a century ago i.e. to achieve ulcer healing and allow biliary drainage while preventing biliary reflux. CONCLUSIONS: This case report draws the readers' attention to this unusual complication of a rare condition, which nonetheless can be an unsuspected finding at laparotomy for a perforated duodenal ulcer.

Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome)

Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

Successful Multi-Modality Endoscopic Treatment of Bouveretʼs Syndrome without Surgery

Purpose: An 85-year-old man with dementia and diabetes presented with lethargy, nausea, and coffee-ground emesis. Vital signs were stable and laboratory examination was notable for a leukocytosis, hematocrit of 33%, and normal liver tests. CT scan showed a distended stomach, pneumobilia, and a 3 cm gallstone in close proximity to the duodenum. Endoscopy demonstrated a large gallstone impacted in the duodenal bulb, resulting in gastric outlet obstruction. Given the patient's age and comorbitidies, the patient's surgeon requested endoscopic management. During the course of three endoscopies, the stone was fragmented using a combination of a Holmium:YAG laser and an intracorporeal electrohydraulic lithotripter (IEHL). IEHL was more effective in uniformly shattering the stone's softer outer shell, while the laser was more effective in weakening the stone's internal structure by boring holes into its harder, inner core. The largest fragment was extracted using a double-snare technique, which provided extra grip and leverage. A large cholecystoduodenal fistula was visualized with surrounding ulcerated mucosa, and the gastroscope could be easily advanced into the gallbladder lumen. The patient was discharged to a nursing home, without recurrence of symptoms. Discussion. Gastric outlet obstruction by a gallstone migrating through a cholecystoduodenal fistula (Bouveret's Syndrome) was first described in 1896 and is a rare condition, representing fewer than 5% of cases of gallstone ileus. Patients are often elderly with underlying comorbidities which poses significant challenges to both surgeon and endoscopist. Despite modern surgical techniques, mortality is as high as 30%. Since 1985 there are only a few reports of successful management with endoscopy alone, with more than 90% ultimately requiring surgery. Our experience suggests that endoscopists should initiate stone fragmentation with IEHL as first line management, use laser lithotripsy adjunctively, crush stone fragments that are left in the stomach to prevent migration and ileal obstruction, and prepare for multiple endoscopic sessions. The choledochoduodenal fistula does not require closure. With an aging, obese population, we anticipate Bouveret's to become more common and recommend endoscopists become familiar with the multiple options available for effective endoscopic therapy.