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Cholecystoenteric fistula is a rare clinical entity with a reported incidence of 3-5% in patients with cholelithiasis[1] and is associated with gallstones in 90% of cases.[2] The most commonly reported type is the cholecystoduodenal fistula (70- 77%), whereas the cholecystocolic fistula (CF) occurs in 6- 15% of cases.[3,4] Preoperative diagnosis is difficult because in most cases the clinical symptoms and signs are non-specific. We herein describe the case of a spontaneous cholecystocolic fistula in a previously asymptomatic patient with no history of gallbladder disease, who presented with clinical manifestations of severe acute cholecystitis. A brief review of the literature follows.
Case presentation
A 75-year old male patient was admitted with a ten-day history of intermittent right upper quadrant abdominal pain. This pain became progressively worse over the last three days and was associated with fever (38-38.5°C), and several episodes of diarrhoea. He had a medical history remarkable for arterial hypertension but there was no history of gallbladder lithiasis and he was completely asymptomatic. Physical examination revealed marked tenderness, and guarding of the right upper abdomen, whereas his body temperature was 38.3°C. The hemogram revealed a white cell count of 16400/mm3 with 89% neutrophils, and a haemoglobin level of 11.40 g/dL. Laboratory investigation revealed hyperbilirubinemia, 2.93 mg/ dL, direct bilirubin 2.70 mg/dL, ALT 97 IU/L (range 5-40 IU/L), AST 135 IU/L (range 5-40 IU/L), ALP 511 IU/L (range 45-140 IU/L), amylase 62 IU/L (range 27-110 IU/L), GGT 707 IU/L (range 9-40 IU/L). Plain abdominal radiograph was unremarkable, while ultrasonography and oral contrast enhanced computed tomography (CT) scans revealed a thickwalled distended gallbladder containing multiple stones and pericholecystic fluid. At surgery, the initial laparoscopic approach was converted to a right subcostal laparotomy due to extensive inflammatory changes involving the gallbladder, the hepatic flexure of the colon and the greater omentum. After laborious dissection of the inflammatory mass, a fistulous tract between the gallbladder and the hepatic colon flexure was found. A difficult cholecystectomy and a segmental resection of the hepatic colon flexure were performed. The postoperative patient though was completely asymptomatic.
Discussion
Cholecystocolic fistula is an extremely rare complication of calculous cholecystitis, occurring in 0.13% of cases.[5] In addition, trauma,[6] surgery, gallbladder cancer[7] and spilled gallstones from previous operations[8] have been reported as causative factors. CF occurs more frequently in elderly patients and there is a female preponderance.[5] Clinical signs and symptoms are chronic and non-specific and may be similar to the features of uncomplicated gallstone disease.[1,4] Therefore, the disease is often overlooked unless a complication such as cholangitis, gallstone ileus or haemorrhage occurs.[2,6] Most patients complain of a right upper quadrant abdominal pain, nausea, vomiting and intolerance to fatty meals.[4,6] Our patient though was completely asymptomatic.
Diarrhoea is a well recognized symptom of CF and is the result of the cathartic effect of bile salts directly on the colonic mucosa.[6] Hession et al[5] reported that prolonged diarrhoea of 8-20 weeks duration was the commonest symptom and occurred as the presenting complaint in five of seven reported cases. A variety of diagnostic modalities have been used to diagnose CF including colonoscopy,[9] ERCP,[1,10] multidetectorrow CT scan,[11] endoscopic colon ultrasound,[7] scintigraphy,[12] and barium enema.[5] In addition fistulography has been used in cases where an external fistula is the presenting feature.[8] In our patient abdominal radiography did not reveal any signs of pneumobilia whereas on oral contrast enhanced CT there was no contrast material inside the gallbladder lumen. This possibly happened due to the extensive inflammatory changes, and the fistulous tract was very narrow.
The standard treatment of CF is open cholecystectomy and closure of the fistula eventually with excision.[1] In our patient though, primary closure was not feasible due to severe inflammatory changes and subsequently a segmental colonic resection was performed. With the development of laparoscopic surgery, many reports have described safe laparoscopic approach in the management of CF.[1,10,13,14] Fujitani et al[15] reported a technique of laparoscopic-assisted excision during which the repair of the fistula was undertaken extracorporeally after the gallbladder and the colon were delivered through the umbilical incision. Special care is needed in order to avoid fecal soilage.[4,13,15] Additionally, where the laparoscopic approach is used it is important to ensure that part of the colonic wall is included in the resected specimen. This is necessary in order to rule out a colonic carcinoma at the fistula site and because if unhealthy fistula or gallbladder tissue is left on the colonic wall this may become ischemic leading to perforation.[16]
In conclusion, we described a rare case of a cholecystocolic fistula in a previously completely asymptomatic patient. Although rare, this entity should always be considered in previously asymptomatic patients who present with clinical manifestations of severe acute cholecystitis and diarrhoea. In the presence of extensive inflammatory changes, primary closure of the fistula may not be feasible and a segmental colon resection may be required.
References
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