Case Presentation:
A 77‐year‐old female with a medical history significant for asymptomatic cholelithiasis, diverticulosis and sigmoid resection for a benign mass presented to the emergency department with dull abdominal pain situated in the epigastric region for the past 1 week which she reported was radiating into her chest. Abdominal examination was benign, as well as liver function tests, which did not show any abnormality. She was given a GI cocktail which did not help in completely relieving the pain. An electrocardiogram did not show any new changes. A computed tomography of the abdomen with oral contrast was done that showed pneumobilia with evidence of air in both the intra‐and extra‐hepatic biliary systems. This was thought to be due to a previous cholecystectomy resulting in an incompetent sphincter and reflux of air into the distended appearing common bile duct. Patient denied having any abdominal surgery except for the colon resection. An endoscopic ultrasound was done for further evaluation, which showed cholelithiasis and either cholecystoduodenal or choledochoduodenal fistula. Open cholecystectomy with stapled closure of duodenal fistula was done at a later date with confirmation of cholecystoduodenal fistula.
Discussion:
A cholecystoduodenal fistula is a connection between the gallbladder and the duodenum. It may occur as an uncommon complication of chronic cholecystitis when the gall bladder becomes adherent to the adjacent duodenum and a stone ulcerates through the wall to form a cholecystoduodenal fistula. The fistula allows decompression of the gall bladder and passage of the gall stones from the gall bladder into the duodenum, and also allows gas to enter the biliary tree. Most fistulas form insidiously and are usually not detected until surgery unless there is associated gallstone ileus. Patients are typically female and elderly with other factors such as gallstones larger than 2cm, long history of biliary disease and episodes of acute cholecystitis facilitating fistula formation. Patients may have symptoms related to cholecystitis such as pain in the right upper quadrant, nausea, vomiting, and fatty food intolerance, but they are not helpful in suggesting a fistula. The most useful techniques for diagnosis are a plain film of the abdomen, endoscopic ultrasound, biliary scintigraphy, and endoscopic retrograde cholangiopancreatography. Although a diagnosis of cholecystoduodenal fistula is rarely suspected clinically, it should be considered in elderly patients with unexplained pneumobilia. The standard treatment of a cholecystoduodenal fistula is open cholecystectomy and closure of the fistula.
Conclusions:
Our case highlights the importance of further diagnosis required in a patient with abdominal pain and asymptomatic gallstones. Complications, such as cholecystoduodenal fistula should be considered as the first manifestation of previously asymptomatic gallstone disease.