Choledochoduodenal fistula in Mainland China: a review of epidemiology, etiology, diagnosis and management

Abstract

PurposeCholedochoduodenal fistula (CDF) is an extremely rare condition even in the most populous nations. However, diagnostic tools are inadequate for the young surgeon to be made aware of such a rare condition before surgery. Hence, basic understanding of the epidemiology, etiology, and management for this unusual but discoverable condition are necessary and essential.MethodsThe exclusive case reports of CDF, which were published from 1983 to 2014 concerning mainland Chinese people, were performed to review the epidemiology, etiology, and management.ResultsA total of 728 cases were incorporated into this review among 48 papers. More than half of the CDF cases were female (416) with an average age of 57.3 years. CDF was usually caused by cholelithiasis (573 of 728). Epigastric pain (589 of 728) and cholangitis (395 of 728) were the most common symptoms of CDF. CDF was usually detected and confirmed by endoscopic retrograde cholangiopancreatography (ERCP) (475 of 728) in Mainland China. The fistulas larger than 1 cm (82 of 654) were recommended for surgical biliary reconstruction. Fistulas between 0.5 cm and 1.0 cm (467 of 654) which were followed frequently by cholangitis attacks also required surgery; the rest were recommended to have stone removal and/or the application of an effective biliary drainage. Fistulas less than 0.5 cm (105 of 654) were usually received conservative therapy.ConclusionCDF should be considered in differential diagnosis of recurrent epigastric pain and cholangitis. A possible ERCP should be arranged to investigate carefully. Depending on the size of fistula and clinical presentation, different programs for CDF are indicated, ranging from drug therapy to choledochojejunostomy.

Choledochoduodenal fistula in the setting of Crohn’s disease

“…Regardless of the etiology, CDFs are often asymptomatic [1], [2], [3], [4], [5], [6], [10]. Symptoms of ascending cholangitis are infrequently observed and previously reported cases have demonstrated evidence of a long-standing CDF without a history suggestive of cholangitis [1], [10], [11].…”

“…Identifying a CDF on imaging is often necessary in its diagnosis as it is frequently clinically asymptomatic [4], [5], [6], [10]. MRCP is less invasive than ERCP and has become an accepted technique in thoroughly examining the intrahepatic and extrahepatic biliary system [14].…”

“…The treatment of a CDF depends on its etiology, severity, and the overall clinical condition of the patient, especially as a standard management of this condition has not been established [6]. If the CDF occurs as a complication of a perforated duodenal ulcer, the patient would need to be appropriately treated medically or surgically, depending on the severity of the ulcer.…”

“…A CDF most commonly arises in the setting of choledocholithiasis, cholelithiasis, or a perforated duodenal ulcer [1], [2], [3], [4], [5]. CDFs have also been reported as a complication secondary to recurrent biliary infections, adjacent neoplasm, tuberculosis, radiation, and iatrogenic injury [6], [7], [8]. To the best of our knowledge, there has been only one reported case of a CDF occurring in the setting of Crohn’s disease (CD) to date [9].…”

“…In fact, they are often found incidentally on imaging, including endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) [4], [5], [6], [10]. If symptoms are present, they are frequently related to the primary cause of the CDF.…”