Cholecysto-duodenal fistula as the source of upper gastrointestinal bleeding

Abstract

A 44-year-old woman was admitted with recurrent hematemesis. She had a history of intermittent upper abdominal pain, which was investigated by computed tomography (CT) scan 1 year prior to the presentation (• " Fig. 1). She was taking aspirin for ischemic heart disease. On examination, her heart rate was 110 bpm and she had postural hypotension. She was febrile (38.7°C) and had epigastric tenderness. Blood results were abnormal: white blood cells 17.0 × 10 3 cells/ μL, C-reactive protein 136 mg/L, and alkaline phosphatase 515 IU/L (normal range 70 -300 IU/L). Glasgow-Blatchford and Rockall scores were elevated at 11 and 8, respectively. Findings at gastrointestinal endoscopy and CT scan are shown in Fig. 2 and• " Fig. 3.Biliary-enteric fistula (BEF) is a rare cause of upper gastrointestinal bleeding. Cholecysto-duodenal fistula (CDF) is the commonest type of BEF [1]. The common causes of CDF include gallstones, peptic ulcer disease, malignancy, and trauma/ surgery. Definitive management is cholecystectomy, resection of the fistula, and intraoperative cholangiography. Diagnosis is made by CT, endoscopic retrograde cholangiopancreatography, or laparoscopic cholecystectomy [2]. Proximal CDFs located in the posterior wall of the duodenal bulb are usually secondary to peptic ulcer disease whereas distal CDFs, which are located in the periampullary region, connect to the distal 2 cm of the bile duct and are more commonly associated with biliary stones [3]. Our patient had symptoms of biliary colic and had gallbladder calculi on initial CT scan. She had recurrent hematemesis during episodes of cholangitis. She was treated conservatively with antibiotics and underwent successful elective open cholecystectomy with repair of the CDF. BEFs involving the duodenal bulb secondary to cholelithiasis are uncommon. CT allows visualization of the fistulas, air in the bile duct, and contraction of the gallbladder, and differentiates between cholecysto-enteric and choledocho-enteric fistulas [4]. We believe that this case highlights the importance of CT imaging in patients with upper gastrointestinal bleeding and unusual endoscopic findings. 3 Curved coronal portal phase computed tomography image demonstrating a gas-filled biliaryenteric fistula extending from the gallbladder to the duodenum (arrows). There is also gas in the gallbladder. A high attenuation metallic hemostasis clip can be seen at the medial end of the fistula. Cases and Techniques Library (CTL) E250Mohammed N et al.

Risk factor and outcome for intra-abdominal bleeding in patients with enterocutaneous fistula

“…[14,18,19] Some other literatures involving bleeding were about aorto-enteric fistula or cholecysto-duodenal fistula. [20,21] There was no literature investigating intra-abdominal bleeding in ECF patients directly. To our knowledge, this was so far the first study that investigated intra-abdominal bleeding in ECF patients, which included the risk factors, managements, and outcome.…”

“…It was easy for duodenum fluid to corrode these vessels or tissue around it and caused a bleeding, which had been mentioned in some case reports. [20,22,23] A hemorrhage history meant that the patient had experienced a loss of blood and had a high possibility of receiving excessive fluid resuscitation and component blood transfusion, which would cause a loss or a dilution of blood coagulation factor, leaving this sort of patient with a potential coagulation disorder. [24,25] When exposed to corrosive intestinal juice, the vessels ever damaged or not were easier to bleed again.…”

An Unusual Presentation of Cholecystoduodenal Fistula: Massive Upper Gastrointestinal Bleeding

“…Only slight melena occurred in some cases [19]. Table 1: Clinical features of previous English-language publications of cases with UGIB as the presenting symptom of CDF [5][6][7][8][9][10][11][12][13].…”

“…Massive UGIB, caused by CDF, is rare with only few cases reported in the literature [5][6][7][8][9][10][11][12][13]. Demonstrating the fistula as the cause of bleeding is difficult, and the majority of non-obstructive biliary-enteric fistulas cases will be found incidentally only in the operating room.…”

“…We report the 10th English-language published case of a CDF that presented with hemorrhagic shock due to massive UGIB [5][6][7][8][9][10][11][12][13]. The inconclusive Esophagogastroduodenoscopy (EGD) findings led us to perform an abdominal CT and the combination of these two modalities made the diagnosis of bleeding from CDF.…”