CASE 15149 Published on 01.11.2017
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Spontaneous benign cholecysto-colonic fistulisation

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
Connected authors
Patient

64 years, male

Categories
Area of Interest Biliary Tract / Gallbladder ; Imaging Technique CT
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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.
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].
Differential Diagnosis List
Spontaneous benign (gallstone-related) cholecysto-colonic fistulisation
Gallbladder carcinoma invading the colon
Cholecysto-duodenal fistulisation
Acute cholecystitis
Chronic cholecystitis
Gallstone ileus
Fistulising colonic diverticulitis
Final Diagnosis
Spontaneous benign (gallstone-related) cholecysto-colonic fistulisation
Case information
URL: https://www.eurorad.org/case/15149
DOI: 10.1594/EURORAD/CASE.15149
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Unenhanced and post-contrast multidetector CT

Unenhanced and post-contrast multidetector CT
Pre-(a) and post-contrast (b-e) images confirmed overdistended stomach (o) with abundant stagnant fluid and air-fluid level. The gallbladder showed contracted lumen (*), marked circumferential mural thickening (arrowheads).
Unenhanced and post-contrast multidetector CT
Post-contrast (b-e) images confirmed overdistended stomach (o) with air-fluid level and fluid-filled duodenal bulb (+). The gallbladder showed contracted lumen (*), marked circumferential mural thickening (arrowheads) with stratified enhancement.
Unenhanced and post-contrast multidetector CT
The hepatic flexure and proximal transverse colon showed marked mural thickening (arrow) with oedematous submucosa and enhancing mucosa.
Unenhanced and post-contrast multidetector CT
Focused oblique-coronal and sagittal reformations (d,e) showed fluid-attenuation fistula (thin arrows) piercing through the thickened gallbladder and communicating with the oedematous colonic flexure (arrows).
Unenhanced and post-contrast multidetector CT
Focused oblique-coronal and sagittal reformations (d,e) showed fluid-attenuation fistula (thin arrows) piercing through the thickened gallbladder and communicating with the oedematous colonic flexure (arrows).
Figure 2

Post-surgical contrast-enhanced CT

Post-surgical contrast-enhanced CT
Coronal (a) and axial (b,c) images showed early postoperative status after cholecystectomy plus resection of hepatic flexure of the colon. Note simple fluid collection occupying gallbladder fossa (§), distended small bowel loops consistent with ileus.
Post-surgical contrast-enhanced CT
Coronal (a) and axial (b,c) images showed early postoperative status after cholecystectomy plus resection of hepatic flexure of the colon. Note simple fluid collection occupying gallbladder fossa (§), distended small bowel loops consistent with ileus.
Post-surgical contrast-enhanced CT
Coronal (a) and axial (b,c) images showed early postoperative status after cholecystectomy plus resection of hepatic flexure of the colon. Note simple fluid collection occupying gallbladder fossa (§), distended small bowel loops consistent with ileus.
Figure 3

Plain chest and abdomen radiographs

Plain chest and abdomen radiographs
Postero-anterior chest (a) and upright abdominal (b) radiographs showed gastric overdistension with abundant intraluminal stagnant fluid and air-fluid level (arrowa). Very scarce air in the small bowel and colon.
Plain chest and abdomen radiographs
Postero-anterior chest (a) and upright abdominal (b) radiographs showed gastric overdistension with abundant intraluminal stagnant fluid and air-fluid level (arrows). Very scarce air in the small bowel and colon.