Cholecystoenteric fistula

Case contributed by Dr Jayanth Keshavamurthy

Presentation

Chronic right upper quadrant pain, nausea, weight loss and loss of appetite.

Patient Data

Age: 65 years
Gender: Male
CT

CT abdomen

Post contrast CT in portal venous phase imaging showing a gall bladder which is not normal. GB is very inflamed with ill-defined fluid collections adjacent to gall Bladder, anterior to liver, inflammatory changes in the ascending colon, hepatic flexure and duodenum. Air in the GB fossa and in duodenum, should increase the radiologist's suspicion for a complication of chronic cholecystitis like a cholecystoduodenal fistula.

Nuclear medicine

Hepato biliary imaging after ERCP

Hepatobiliary scan with no uptake into the gall bladder suggesting cystic duct obstruction. The tracer is flowing normally into the duodenum without a biliary leak.

X-ray

Percutaneous cholangiogram after all studies.

PTC showing the connection between

1. the gall bladder and duodenum,

2. There is leak of contrast from gall bladder fundus.

3. There is a stent in the pancreatic duct.

CT

3 days after first CT and immediately after ERCP

CT scan with contrast showing an inflamed GB and air in the GB fossa with severe pericholecystic inflammatory changes. However, there is an improvement in the fluid collection from the CT 3 days prior. Differential diagnosis include gangrenous cholecystitis with cholecystoenteric fistula. This was confirmed on PTC performed subsequently.

Case Discussion

He had an initial single phase CT which was abnormal and was referred for ERCP which was done 3 days after first CT. They had difficulty to cannulate the CBD but could place a stent in pancreatic duct.

A repeat CT was done after ERCP. Small amount of pus was seen in the duodenum suspecting a cholecysto duodenal fistula.

This was confirmed by PTC.

Patient underwent a satisfactory PTC placement of a cholecystostomy tube and 8 weeks later under cholecystectomy which showed chronic cholecystitis and perforation without any cancer.

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Case information

rID: 68368
Published: 20th Jun 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included
Institution: Augusta University

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