The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Cholecystoduodenal Fistula

Large gallstones could erode through gallbladder wall to nearby structures, causing fistulas, gastric outlet obstruction and gallstone ileus. They typically occur in elderly patients with comorbidities carrying therapeutic challenges. We present a case of a middle-aged woman who was thought to have symptomatic cholelithiasis. Extensive adhesions precluded safe cholecystectomy. While hepatobiliary iminodiacetic acid scan and magnetic resonance imaging with cholangiopancreatography (MRI-MRCP) failed to visualize the gallbladder, computed tomography (CT) was consistent with cholecystoduodenal fistula. A very large gallstone was seen endoscopically in the duodenum, which was broken down into pieces using a large stiff snare.

Concurrent cholecystoduodenal fistula and primary aortoenteric fistula

ABSTRACT Bilioenteric fistulae are a rare complication and can pose a diagnostic challenge owing to non-specific symptomology. When occurring with an aortoenteric fistula, it represents a rare and potentially life-threatening disease state. We present the case of a 77-year-old gentleman initially treated as presumed ascending cholangitis. This was complicated by upper gastrointestinal bleeding secondary to an aortoenteric fistula and cholecystoduodenal fistula.

Gallstone Ileus with Resolution of Bile Leak Post-Subtotal Cholecystectomy and Spontaneous Closure of Cholecystoduodenal Fistula: Case Report and Literature Review

Gallstone ileus (GSI) is a mechanical intraluminal bowel obstruction caused by biliary calculi through the biliary-enteric fistula. This is a rare sequela of cholelithiasis occurring in 0.3 – 1.5% of patients with worrying mortality of 11.7 – 20%. This is a case of GSI in a 67-year-old woman who presented with small bowel obstruction secondary to impaction of biliary calculi at terminal ileum with underlying cholecystoduodenal fistula (CDF). Enterolithotomy with stone extraction (ES) was performed, followed by subtotal reconstituting cholecystectomy due to iatrogenic gallbladder perforation. The diagnosis of GSI is ascertained by the presence of the Rigler’s triad on abdominal X-ray, while CDF was demonstrated by post-surgery CT images. Bile leak post-operation was managed conservatively based on the SNAP (Sepsis, Nutrition, Anatomy, Plan) approach, and spontaneous closure of CDF was observed. In a nutshell, GSI should always be kept in mind as a differential diagnosis of mechanical bowel obstruction, especially among elderly female patients. Radiological findings of Rigler’s triad aid clinical diagnosis of GSI. Despite its rare incidence, early diagnosis is crucial as it is readily treatable with surgery. ES alone is the gold standard in the management of GSI.

282 Cholecystoappendicular Fistula- 1st Ever Reported Case

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.

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.

939 Enterovaginal Fistula; Could It Be Gallstones?

This is a rare presentation of an impacted gallstone leading to a ileovaginal fistula. A 76-year old female presented with a 4 week history of faecal vaginal discharge and weight loss on a background of endometrial cancer treated with chemotherapy and radiotherapy 9 years ago. She was initially investigated with a pelvc MRI which showed a collection in the vaginal stump. A further abdominal and pelvic CT scan revealed a cholecystoduodenal fistula complicated by an ileovaginal fistula at the point of impaction. The patient underwent a laparotomy with small bowel resection and anastomosis. She was admitted to the intensive care unit post operatively and recovered well. There are no previous reports of a vaginal fistula caused by gallstone ileus. This case highlights a rare complication of gallstones in a patient who has undergone pelvic radiotherapy.