CASE 2932 Published on 20.07.2005

A case of spontaneous cholecystocutaneous fistula

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Devalia H, Johnson T

Patient

93 years, female

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Clinical History

This case report describes an elderly lady, who presented to us with a spontaneously discharging abdominal wound. Fistulography results confirmed a cholecystocutaneous fistula.

Imaging Findings

A 93-year-old lady was referred to us by her general practitioner for a discharging sinus from the anterior abdominal wall for the past 3 months. She denied having any previous gastrointestinal or biliary symptoms. She had a past medical history of severe obstructive pulmonary and ischaemic heart disease. On examination, it was found that she had a 1.5 cm wound in her right hypochondrium which was discharging pus. The discharge was sent for a microbiological examination. Full blood count and liver function tests values were found to be within normal limits. An ultrasound examination of the abdomen showed a large, thick walled gallbladder with a stone stuck at the neck. The fistulogram showed a cholecystocutaneous fistula, a large gallbladder stone, and a normal biliary tree. The patient did not give her consent for surgery, and she refused to undergo any further intervention.

Discussion

A spontaneous cholecystocutaneous fistula is a rare complication of gallbladder empyema when left untreated.Only a few cases are reported over the past 50 years (1,2,3). The external orifice of the fistula tract can occur anywhere from the anterior chest wall above the costal margin to the gluteal region below the iliac crests (2 ). In the majority of cases, a distinct episode of previous cholecystitis is absent (2). A spontaneous cholecystocutaneous fistula has been reported to be secondary to abdominal trauma, previous surgery, cholelithiasis, biliary malignancy and acalculous cholecystitis (1). The fistula can occur following a subcutaneous herniation of a pathologically dilated gallbladder. Adhesions between the gallbladder and the abdominal wall may result in a perforation through the abdominal wall (4). The common differential diagnoses are pyogenic granuloma, infected sebaceous cyst or metastatic carcinoma (1). Identification of an enteric pathogen on pus culture should suspect the visceral source (1). The diagnosis is usually confirmed by seeing the fistulogram. The traditional treatment consists of administering broad-spectrum antibiotics, cholecystectomy and fistula drainage. A one stage treatment is the preferred option. A laparoscopic approach appears feasible even though the conversion rate is high. Mymin JS et al believe that surgery is not always required or even not appropriate as the majority of cases tends to occur in elderly patients with systemic disease (5).

Differential Diagnosis List

Cholecystocutaneous fistula.

Final Diagnosis

Cholecystocutaneous fistula.

References

[1] Chang SS, Lu CL, Pan CC, Chiou YY, Wang SS, Chang FY, Lee SD.
Spontaneous cholecystocutaneous fistula presenting with a cellulitis and portal vein thrombosis.
J Clin Gastroenterol. 2002 Jan; 34(1): 99-100. (PMID: 11743257)

[2] Nicholson T, Born MW, Garber E.
Spontaneous cholecystocutaneous fistula presenting in the gluteal region.
J Clin Gastroenterol. 1999 Apr; 28(3): 276-7. (PMID: 10192624)

[3] Birch BR, Cox SJ
Spontaneous external biliary fistula uncomplicated by gallstones.
Postgrad Med J. 1991 Apr; 67(786): 391-2. (PMID: 2068038)

[4] Ulreich S, Henken EM, Levinson ED.
Imaging in the diagnosis of cholecystocutaneous fistulae.
J Can Assoc Radiol. 1983 Mar;34(1):39-41. (PMID: 6221018)

[5] Mymin JS, Watkins RM.
Spontaneous cholecystcutaneous fistulae secondary to calculous cholecystitis.
Br J Clin Pract. 1993 Nov-Dec;47(6):341-2. (PMID: 8117563)

Case information