Spontaneous biliary-enteric fistula is a well recognized though uncommon disorder. Whereas cholecystoduodenal fistula accounts for 90% of biliary-enteric fistulas, the choledochoduodenal fistula (CDF) is a rarer type.1,2 The majority of the former fistulas are caused by cholelithiasis, whereas 80% of CDFs are due to duodenal ulcer. Jaundice or cholangitis is a rare complication of duodenal ulcer-related CDF.3,4 Most CDFs are discovered incidentally during a plain abdominal radiograph or an upper gastrointestinal barium series. Endoscopy has been used infrequently for visualization and delineation of the fistulous communication. 5,6The present reports describe two patients with duodenal ulcer that perforated into the common bile duct and subsequently was complicated by cholangitis in one patient. The role of endoscopy in the diagnosis of CDF is stressed. A review of the modern management of CDF is also outlined. Case Reports Case 1:A 44-year-old Indian nonsmoking male doctor with a 10-year history of proven recurrent duodenal ulcer was referred to us for the evaluation of biliary-enteric fistula. He has been on regular H 2 antagonist medication for the last five years. He suffered three episodes of cholangitis during the previous 14 months. The investigations during the second episode of cholangitis at another hospital led to the suggestion of biliary-enteric fistula based on gas in the biliary tree on the plain radiograph of the abdomen (Figure 1) and ultrasonography. The upper gastrointestinal endoscopy showed grossly deformed duodenal bulb with an active ulcer and narrowing. An attempt at endoscopic retrograde cholangiopancreatography (ERCP) failed because of the duodenal narrowing. Upper gastrointestinal (UGI) barium series was not performed at this stage. The patient was given anti-ulcer therapy. Four months later, while on treatment, he developed another episode of cholangitis and was referred to us for evaluation one month later.Physical examination was normal. Laboratory data showed elevated alkaline phosphatase 260 IU/L (normal <170 IU/L); serum amylase and gastrin levels were normal. The examination of UGI tract with pediatric fiberendoscope revealed grossly deformed duodenal bulb with narrowing and an active ulcer at the apex. An opening 2 mm in diameter was seen within the ulcer, through which bile and air were exuding, bathing the ulcer. The postbulbar area was entered with great difficulty and was normal. The opening was cannulated with a standard ERCP catheter and on injection of contrast, the common bile duct (CBD) was visualized along with the gallbladder (Figure 2). The duct was dilated to 12 mm with narrowing at its lower end and the gallbladder was normal. The CBD retained enough contrast one hour later to suggest delayed drainage (Figure 3). The ERCP was not possible to perform due to the degree of duodenal deformity and narrowing.Surgery was performed which included gastrojejunostomy, vagotomy and Roux-en-Y choledocho-jejunostomy. The findings included chronic penetrated duodenal ulcer with ...