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Abstract
Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.
- Pancreas and biliary tract
- General surgery
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Background
Cholecystogastric and cholecystocolonic fistulae are abnormal connections between the gallbladder with either the stomach or the colon. They are rare complications of longstanding chronic calculous cholecystitis with incidence rate of 2% and 8%–26.5% of all gallbladder fistulae, respectively.1–3 The combined presence of cholecystogastric and cholecystocolonic fistula has not been reported in the literature thus far. The diagnosis of these fistulae is usually made intraoperatively as symptoms are typically non-specific.1–6 Surgical resection of the fistula with cholecystectomy is recommended in patients when appropriate, although there is continued debate on whether laparoscopic or open surgery is the best approach.4 5
Case presentation
A man in his 40s with a Body Mass Index of 30 kg/m2, hypertension, alcohol use, medical history of polycythaemia and a 15 pack-year smoking history was admitted to the hospital from the emergency department with a chief complaint of moderate to severe epigastric pain radiating to the right upper quadrant. The patient’s vital signs were all within the normal range: temperature of 37.2°C, blood pressure of 114/71 mm Hg, pulse rate of 86 beats per minute and respiratory rate of 20 breaths per minute. Laboratory values include elevated white cell count of 12.3 x 109/L, elevated red blood cell count of 6.88 x 1012/L, high haemoglobin level of 216 g/L, high haematocrit level of 63.8% and normal platelet count of 228 x 109/L. Liver function tests include normal alkaline phosphatase of 74 U/L, slightly elevated alanine aminotransferase of 46 U/L and aspartate aminotransferase of 60 U/L. Albumin was 4.6 g/dL, and total bilirubin was elevated at 1.9 mg/dl.
He also reported nausea, vomiting, diaphoresis and an episode of diarrhoea. Physical examination showed no signs of jaundice but tenderness in the right hypochondrium on palpation.
Investigations
Same-day abdominal and pelvic CT scan with contrast showed slightly dilated and fluid-filled proximal small bowel with decompressed distal one-third of small bowel, suggestive of partial small bowel obstruction (SBO), and a partially contracted gallbladder with gallstones and pneumobilia (figure 1). He was hydrated, kept nil per os (NPO) and given pain medication. The patient stated that he had symptomatic gallstones for 7–8 years but declined surgery and instead opted for observation with dietary modification. Due to concern for SBO, patient was made NPO in preparation for enteroclysis or small bowel follow-through study, which was performed on hospital day 2. This was unremarkable with no evidence of mechanical bowel obstruction. Abdominal ultrasound showed partially contracted gallbladder with stones and sludge, thickened gallbladder wall measuring 3.2 mm, dilated intrahepatic and extrahepatic biliary system with common bile duct (CBD) measuring 8 mm and hepatomegaly (figure 2). Findings were concerning for cholecystitis and choledocholithiasis. Liver function tests (LFTs) were noted to be elevated, and the patient was given empiric intravenous antibiotics for cholecystitis. Nasogastric tube was placed and set to low intermittent suction.
Abdominal CT showing (A) dilation of the small bowel, (B) collapsed gallbladder and (C) slight pneumobilia.
Abdominal ultrasound showing (A) increased gallbladder wall thickening (0.32 cm) and (B) increased common bile duct diameter (0.80 cm). CBD, common bile duct; GB, gallbladder.
On day 3 of admission, magnetic resonance cholangiopancreatography (MRCP) found no evidence of choledocholithiasis. However, there was mild dilation of CBD at 6.3 mm, suggestive of stricture in the distal CBD, and contracted gallbladder with small gallstones (figure 3). Stool studies were positive for norovirus, and the patient was placed on enteric isolation. No endoscopic retrograde cholangiopancreatography was planned.
Magnetic resonance cholangiopancreatography showing contracted gallbladder. CBD, common bile duct.
Differential diagnosis
The differential diagnosis included SBO, as initially evidenced on abdominal and pelvic CT, cholecystitis or choledocholithiasis with CBD dilation on further imaging with ultrasound. No findings indicative of choledocholithiasis were evident on MRCP.
Treatment
He underwent scheduled laparoscopic cholecystectomy with intraoperative cholangiography for acute calculus cholecystitis on day 4 of admission. Intraoperative findings showed large adhesions in the RUQ, a portion of the colon adherent to the gallbladder fundus and the stomach attached to the liver bed medially with the omentum on top (figure 4A). Once dissected, the contracted gallbladder was noted to be attached to both the stomach and colon, indicating combined cholecystocolonic and cholecystogastric fistulae (figures 4B and 5). Indocyanine green (ICG) fluorescence dye was injected for better visualisation of the biliary tree and to avoid injury to the bile duct. It also showed passage of contrast from gallbladder to both colon and stomach. Nasogastric tube was placed. The cholecystocolonic fistula was taken down and divided using laparoscopic gastrointestinal anastomosis (GIA) stapler with wedge resection of the antimesenteric portion of the colon transversely from the gallbladder fundus to prevent narrowing of the colon. The colon was devoid of faecal matter due to NPO status for concern of SBO and subsequent enteroclysis. This was followed by takedown of the cholecystogastric fistula using the same GIA staple in transversely to the stomach. The gallbladder with the connecting colonic and gastric fistula was removed completely without complications. The small bowel and colon were examined laparoscopically for any gallstone ileus. There was no evidence of obstruction or gallstone ileus, which could have been passed by the patient prior to the operation.
(A) Intraoperative imaging of the stomach attached to the liver medially with the omentum (white arrow) on top. (B) Intraoperative imaging of the cholecystogastric fistula (yellow arrow) between the stomach and the gallbladder (GB). (C) Line diagram, created by Dr Ariel Santos, illustrating cholecystogastric (purple arrow) and cholecystocolonic (blue arrow) fistulae.
Intraoperative imaging of the cholecystocolonic fistula (arrow) noted after takedown of the cholecystogastric fistula. GB. gallbladder.
Outcome and follow-up
Patient had an uneventful recovery with improvement of LFTs. Nasogastric tube was removed the next day, and diet was started. He was discharged 3 days after cholecystectomy. Pathology showed acute on chronic cholelithiasis with no malignancy noted. The gastroenterology service and his primary care physician are aware of the mild stricture noted on initial MRCP. The patient is being followed in an outpatient basis.
Discussion
Cholecystoenteric fistulae are rare complications of gallbladder disease, with an incidence of about 0.9%–5%.5 7 Fistula formation results from chronic cholelithiasis with cholecystitis in which inflammation and erosion of the gallstones create pressure on the enteric lumen.1 8 Cholecystoenteric fistulae in order of prevalence are cholecystoduodenal (77%–90%), cholecystocolonic (8%–26.5%), choledochoduodenal (5%) and cholecystogastric (2%).1 3 Most are diagnosed incidentally during the initial operation as these fistulae present with non-specific symptoms.1 2 5 6 8 Cholecystogastric fistulae, in particular, are diagnosed intraoperatively 92.1% of the time and often result in a more difficult and unexpected surgery.1 8 Cholecystocolonic fistulae have variable clinical presentations and can be asymptomatic.2 Symptomatic patients can present with chronic diarrhoea, abdominal pain and pneumobilia but may also present with acute onset gallbladder ileus about 25% of the time.1 2 6 9
Additionally, clinicians should be aware of gallstone ileus as an indication of possible fistula.9 Gallstone ileus, which commonly presents with the Rigler triad of pneumobilia, intestinal obstruction and ectopic gallstone, results from gallstone migration to the intestines through a cholecystoenteric fistula.10 There is a debate on the need for cholecystectomy and takedown of cholecystoenteric fistula in combination with enterolithotomy during the initial operation or as a delayed operation following simple enterolithotomy.11 12 One study in 1994 showed a 16.9% mortality rate with combined enterolithotomy, cholecystectomy and fistula closure versus a 11.7% mortality rate for simple enterolithotomy alone.13 Simple enterolithotomy for gallstone ileus management may be preferred in high-risk patients such as elderly patients with many comorbidities. However, for low-risk patients, single-stage operation with combined management of enterolithotomy, cholecystectomy and fistula takedown may be preferred because it can eliminate future morbidity (gallbladder carcinoma, cholecystitis, recurrent and chronic pain).11 12 Additionally, acute serious complications with cholecystocolonic fistulas can include colon perforation, fistula division and faecal peritonitis which may lead to sepsis and death.9
Surgical management with a laparoscopic or open approach has been a subject of dispute and depends on the surgeon’s preference.1 9 Laparoscopic cholecystectomies are less invasive, associated with shortened hospital length of stay, and decreased postoperative complications while open conversion allows for improved visualisation and accessibility.14 Rates of open conversion have been reported between 1% and 15% and depend greatly on surgical expertise and associated patient conditions such as obesity, adhesions and anatomical variability.14–16 In patients with severe adhesions and inflammation, open conversion may be needed for better visualisation of the anatomy.1 Additionally, there is variability in whether surgeons perform the cholecystectomy, fistula repair and stone removal in one operation (single-stage approach) versus the two-stage approach where the cholecystectomy is performed later.1
We opted for a laparoscopic approach complemented with ICG angiography. ICG-enhanced fluorescence has been used in numerous open and laparoscopic procedures, including hepatobiliary, plastic, colorectal, renal, and head and neck surgery. ICG is fluorescent near-infrared range (790–805) and metabolised by the liver and excreted in the bile, providing great suitability to image biliary structures with infrared video cameras.17 ICG is commonly used to better visualise biliary anatomy during laparoscopic cholecystectomy to prevent bile duct injury, increasing patient safety and reducing complications.15 17 We successfully managed this challenging case with a single-stage approach performed laparoscopically with the aid of ICG. However, conversion to open might be the safest and prudent thing to do if encountered with difficulties such as poor visualisation of anatomy, bleeding, or faecal contamination. We hope that our experience can be helpful in future management of similar cases.
Learning points
High clinical suspicion is necessary to diagnose cholecystoenteric fistulae in patients with biliary disease considering radiographic findings like pneumobilia.
Consider use of indocyanine green angiography for a safer cholecystectomy and better visualisation of the fistula and biliary anatomy.
Attempt laparoscopic approach to fistula resection and cholecystectomy.
Ethics statements
Patient consent for publication
Footnotes
Twitter @tinazhu_, @FerrisZeitouni, @justinvaughanMD, @traumamd1
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: CZ, FZ and APS. The following authors gave final approval of the manuscript: APS and JV.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.