Teaching Case

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, MD.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org

Patient

64 years, male

Categories

Area of Interest Biliary Tract / Gallbladder ; Imaging Technique CT ;

Procedure Diagnostic procedure ; Special Focus Fistula ;

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Clinical History

A 64-year-old, overweight diabetic male with history of hypertension, hiatal hernia, gastro-oesophageal reflux, colonic diverticulosis and cholelithiasis. Recently (three months earlier) discharged from another hospital with diagnosis of gallstone-related cholecystitis, treated medically. Currently present at the emergency department because of non-peritonitic abdominal distension and painless dark vomiting. Mild elevation of C-reactive protein.

Differential Diagnosis List

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Spontaneous benign (gallstone-related) cholecysto-colonic fistulisation

Gallbladder carcinoma invading the colon

Cholecysto-duodenal fistulisation

Acute cholecystitis

Chronic cholecystitis

Gallstone ileus

Fistulising colonic diverticulitis

Imaging Findings

Initial radiographs (Fig.1) showed gastric overdistension with abundant intraluminal fluid, and very scarce air in the small bowel and colon. Early CT (Fig.2) confirmed distended stomach and duodenal bulb, and showed gallbladder abnormality with contracted lumen, circumferential mural thickening with stratified enhancement. Focused reformations (Fig.2 d,e) identified a thin fluid-attenuation fistula, communicating between the gallbladder and the thickened hepatic flexure with oedematous submucosa and enhancing mucosa.
After nasogastric tube decompression, upper digestive endoscopy showed extrinsic compression on gastric antrum and pylorus, peri-Vaterian mucosal hyperaemia. Colonoscopy showed a 3-cm, centrally depressed lesion with hyperaemic mucosa at the hepatic flexure.
Laparotomic surgery (postoperative status shown in Fig.3) included cholecystectomy with resection of adjacent liver parenchyma, plus segmental colonic resection. Histopathology diagnosed severe acute and chronic transmural gallbladder inflammation, severe lympho-histiocytic extrinsic inflammation of the involved colonic segment, without signs of neoplasia.

Discussion

Currently, gallbladder fistulas are uncommon complications of neglected cholelithiasis, with an estimated incidence 0.6-1.4/1000 patients. The mechanism involves mechanical erosion by gallstones through the inflamed or gangrenous gallbladder wall into the adjacent viscera. Whereas most cases involve communication between the gallbladder and the duodenum, a minority (8-13.6%) are cholecysto-colonic fistulas (CCF) developing at the hepatic flexure due to the close anatomic proximity. CCFs generally occur in advanced age with a female preponderance, as a complication of either recurrent acute or chronic cholecystitis. Compared to cholecysto-duodenal fistulas which lead to gallstone ileus, clinical manifestations of CCFs are varied and nonspecific, such as vague abdominal pain, fever, jaundice, vomiting, appetite and weight loss. Although inconstantly present, the most characteristic features include pneumobilia, chronic watery diarrhoea, and elevated prothrombin time from vitamin K malabsorption. Patients sometimes deny history of cholecystitis and may remain scarcely symptomatic for a long time. [1-4]
The sporadic reported CCF cases have been variably studied with barium enema, colonoscopy, endoscopic or MR-cholangiopancreatography. In the past CCF was often preoperatively undiagnosed, with possible catastrophic consequences such as perforation and faecal peritonitis. Nowadays, in the vast majority of cases this condition will be diagnosed at multidetector CT due to the increasing use of this imaging modality in the emergency department. In first place, detection of pneumobilia without history of biliary surgery or instrumentation suggests the presence of a spontaneous biliary-enteric communication. Cholelithiasis-related CCF generally presents as a shrunken, thick-walled chronic cholecystitis, adherent to the hepatic flexure. As in this case, careful study scrutiny may allow identifying the fistulous track. Gallstones are occasionally found in the colonic lumen [4-6]. The key differential diagnosis is represented by gallbladder carcinoma penetrating into the adjacent large bowel [7-10].
Open or laparoscopic surgical treatment of CCF is recommended to avoid the risk of cholangitis, and requires cholecystectomy with fistula resection [2, 4, 11].

References

[1] Tahir OM, Fedele CR, Sneider MB, et al (2014) Cholecystocolonic fistula. Del Med J 86:373-375 (PMID: 25942791)

[2] Balent E, Plackett TP, Lin-Hurtubise K (2012) Cholecystocolonic fistula. Hawaii J Med Public Health 71:155-157 (PMID: 22787563)

[3] Dickinson CL, Coulston J, Armstrong CP (2009) Gallbladder-colonic fistula: an unusual cause of diarrhoea. BMJ Case Rep 2009 pii: bcr03.2009.1643. doi: 10.1136/bcr.03.2009.1643. (PMID: 22114622)

[4] Savvidou S, Goulis J, Gantzarou A, et al (2009) Pneumobilia, chronic diarrhea, vitamin K malabsorption: a pathognomonic triad for cholecystocolonic fistulas. World J Gastroenterol 15:4077-4082. (PMID: 19705508)

[5] Singh AK, Gervais D, Mueller P (2004) Cholecystocolonic fistula: serial CT imaging features. Emerg Radiol 10:301-302 (PMID: 15278710)

[6] Lim BH, Mack P, Mohan C (1989) Cholecysto-duodeno-colic fistula--a case report. Ann Acad Med Singapore 18:296-297 (PMID: 2774476)

[7] Micu BV, Andercou OA, Micu CM, et al (2017) Spontaneous cholecystocutaneous fistula as a primary manifestation of gallbladder adenocarcinoma associated with gallbladder lithiasis - case report. Rom J Morphol Embryol 3 58:575-58 (PMID: 28730246)

[8] Brieau B, Barret M, Leblanc S, et al (2017) A rolling stone plugging the colon: Consequence of a cholecystocolonic fistula from gallbladder cancer. Presse Med 46:784-785. (PMID: 28669520)

[9] Khosla MS, Nadir A, Ravi J, et al (2016) Invasive Gallbladder Cancer With a Cholecystoduodenal Fistula Allowing Direct Gallbladder Biopsy Through EGD. Am J Gastroenterol 111:1228 (PMID: 27580772)

[10] Rastogi R (2008) Cholecystocolic fistula secondary to gallbladder carcinoma: a rare case. Saudi J Gastroenterol 14:144-146. (PMID: 19568525)

[11] Hida Y, Morita T, Fujita M, et al (1999) Laparoscopic treatment of cholecystocolonic fistula: report of a case preoperatively diagnosed by barium enema. Surg Laparosc Endosc Percutan Tech 9:217-21 (PMID: 10804005)

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