Case Presentation:

Cholelithiasis and cholecystitis are the most common causes of fistulas between the biliary tract and gastrointestinal tract. Inflammation caused by cholecystitis leads to necrosis and erosion of structures surrounding the common bile duct, resulting in fistula formation. The following case provides an atypical presentation of multiple enterobiliary fistulas in a patient presenting with epigastric pain.

Discussion:

A 52–year–old Hispanic female with an in situ gallbladder and a past medical history of uncontrolled diabetes mellitus type II and hypertension presented with an infected lower extremity ulcer. Shortly after admission the patient developed epigastric pain accompanied by nausea and intermittent vomiting. Physical examination of the abdomen was significant for epigastric tenderness with decreased bowel sounds in all quadrants. Liver function tests revealed an AST of 60, ALT 72, alkaline phosphatase 399, albumin 2.8, gamma–glutamyl transpeptidase 452, and normal total bilirubin. Abdominal imaging was perplexing, as a CT of the abdomen was reported as “status post cholecystectomy”. However, an ultrasound of the abdomen disclosed marked echogenicity with shadowing, suggestive of cholelithiasis. Follow–up MRCP revealed a contracted gallbladder with multiple gallstones, as well as a mildly dilated common bile duct measuring 8 mm but without intraluminal bile duct filling defects. HIDA scan failed to visualize the gallbladder. The patient was subsequently taken to surgery for a cholecystectomy, but she was also found to have a choleduodenal fistula. A second fistula between the gallbladder and the transverse colon was also discovered. The patient was also found to have multiple adhesions and gallstones in the peritoneal space.

Conclusions:

The prevalence of unsuspected biliary–intestinal fistulas discovered intraoperatively ranges from 0.86–2.7%. Patients commonly present with symptoms of persistent diarrhea, steatorrhea, electrolyte imbalance, or bleeding from the fistula. Enterobiliary fistulas are most commonly formed between the gallbladder and hepatic flexure of the colon due to anatomic location. However, as illustrated by our case, fistulas may form in other parts of the gastrointestinal tract as well.