Abstract:Spontaneous pneumobilia without previous surgery or interventional procedures indicates an abnormal biliary-enteric communication, most usually a cholelithiasis-related gallbladder perforation. Conversely, choledocho-duodenal fistulisation (CDF) from duodenal bulb ulcer is currently exceptional, reflecting the low prevalence of peptic disease. Combination of clinical data (occurrence in middle-aged males, ulcer history, absent jaundice and cholangitis) and CT findings including pneumobilia, normal gallbladder,… Show more
“…Prolonged medical therapy ultimately allowed resolution of symptoms [Adapted with permission from ref. no [ 22 ]] Fig. 18 A 78-year-old male with history of chronic NSAID use had initial contrast-enhanced CT ( a, b ) finding of circumferential thickening of pylorus and proximal duodenum with oedematous submucosa (*), enhancing mucosa (thin arrows) and posterior ulcer outpouching (arrows); ventrally, the normal-appearing gallbladder (+) was in contact with the affected duodenal bulb.…”
Section: Fistulisationmentioning
confidence: 99%
“…Prolonged medical therapy ultimately allowed resolution of symptoms [Adapted with permission from ref. no [ 22 ]]…”
Section: Fistulisationmentioning
confidence: 99%
“…Surgical management is indicated in cases refractory to medical therapy. Coledochoduodenal fistulas from PUD are very uncommon compared to cholelithiasis-related perforation into a normal duodenum: the latter are suggested by contracted gallbladder with mural thickening, and may give rise to further complications, such as gallstone ileus and Bouveret syndrome [ 7 , 22 , 25 , 27 , 28 ].…”
Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented.Teaching points• Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs
• Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis
• CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs
• Currently the commonest complication, haemorrhage may be treated with transarterial embolisation
• Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation
“…Prolonged medical therapy ultimately allowed resolution of symptoms [Adapted with permission from ref. no [ 22 ]] Fig. 18 A 78-year-old male with history of chronic NSAID use had initial contrast-enhanced CT ( a, b ) finding of circumferential thickening of pylorus and proximal duodenum with oedematous submucosa (*), enhancing mucosa (thin arrows) and posterior ulcer outpouching (arrows); ventrally, the normal-appearing gallbladder (+) was in contact with the affected duodenal bulb.…”
Section: Fistulisationmentioning
confidence: 99%
“…Prolonged medical therapy ultimately allowed resolution of symptoms [Adapted with permission from ref. no [ 22 ]]…”
Section: Fistulisationmentioning
confidence: 99%
“…Surgical management is indicated in cases refractory to medical therapy. Coledochoduodenal fistulas from PUD are very uncommon compared to cholelithiasis-related perforation into a normal duodenum: the latter are suggested by contracted gallbladder with mural thickening, and may give rise to further complications, such as gallstone ileus and Bouveret syndrome [ 7 , 22 , 25 , 27 , 28 ].…”
Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented.Teaching points• Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs
• Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis
• CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs
• Currently the commonest complication, haemorrhage may be treated with transarterial embolisation
• Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation
An 89-year-old man was admitted to the hospital with fever of 3 days' duration. He had undergone cholecystectomy and common bile duct exploration 30 years earlier because of gallstone disease. The patient also had symptoms of cholangitis and cholelithiasis (• " Fig. 1). Considering his advanced age, we planned to perform endoscopic retrograde cholangiopancreatography (ERCP) first to relieve his symptoms and reduce the inflammatory reaction. After inserting a duodenoscope, we found a fistulous orifice, about 1.5 cm in diameter, located in the descending duodenum. Guidewire placement and radiography confirmed the presence of a choledochoduodenal fistula (CDF) (• " Fig. 2 a ,b and• " Fig. 3 a ,b). We then exchanged the duodenoscope for a gastroscope. The gastroscope, with a 7.5-Fr Tri-Ex Extraction Balloon (Cook Medical, Winston-Salem, North Carolina, USA) in the working channel, was inserted over the guidewire into the intrahepatic bile duct (• " Fig. 2 c and • " Fig. 3 c) under
“…Notably, duodenal ulcer per se can cause fistula to other organs such as duodeno-pleural [8], duodeno-portal [9], or duodeno-ureteric fistula [10]. Being a rare complication of peptic ulcer disease [11], its diagnosis and management remains challenging. However, with the recent advances in hepato-biliary imaging techniques, suspecting this entity has become more plausible [12], and thanks to these available endoscopic approaches, confirming the presence of choledochoduodenal fistula has become attainable in most cases [12].…”
Patient: Female, 29
Final Diagnosis: Choledocho-duodenal fistula
Symptoms: Abdominal pain • nausea • vomiting
Medication: —
Clinical Procedure: Gastro-jejunostomy • hepatico-jejunostomy
Specialty: Surgery
Objective:
Rare co-existance of disease or pathology
Background:
Choledochoduodenal fistula is an uncommon complication secondary to peptic ulcer disease. Determining this diagnosis is challenging especially when confronted with unspecific physical and radiological findings.
Case Report:
Here we report a case of a 29-year-old Ethiopian female who presented to Geitaoui University Hospital in Beirut, Lebanon with epigastric pain and was diagnosed to have of choledochoduodenal fistula.
Conclusions:
Choledochoduodenal fistula is a rare complication of duodenal ulcer and this case report may help clinicians to identify suspected cases of this entity with similar presentations.
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