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

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.

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).