Cholecystoduodenal Fistula Diagnosed with Contrast-Enhanced Endoscopic Ultrasound
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E18 Cases and Techniques Library (CTL) Cholecystoduodenal fistula diagnosed with contrast-enhanced endoscopic ultrasound A 58-year-old man with a history of Fig. 1 Computed Crohn’s disease (A2L2B1p), bile stones, tomography (CT) image migraine, and chronic depression present- obtained after the ad- ed with an 11-kg weight loss and asthenia ministration of intra- during the preceding 6 months. He was venous contrast show- receiving treatment with infliximab, aza- ing calcification of the thioprine, mirtazapine, and lorazepam. gallbladder wall, the Laboratory tests showed a slightly elevat- absence of a cleavage plane between the ed C-reactive protein (CRP) of 35 mg/dL. second portion of the He underwent a computed tomography duodenum (D) and the (CT) scan that demonstrated gallbladder- gallbladder (G). wall calcification, with no cleavage plane between the second portion of the duode- num and the gallbladder (●" Fig.1). Upper gastrointestinal endoscopy showed Fig. 2 View during that the duodenal bulb had a bulky ap- upper gastrointestinal pearance with ulceration of the anterior endoscopy showing duodenal wall (●" Fig.2). Luminal con- a bulky appearance trast-enhanced endoscopic ultrasound of the duodenal bulb, with ulceration of the (EUS) with instillation of a 50/50 poly- anterior duodenal wall. ethylene glycol and distilled water solu- tion was used to create a hyperechogenic lumen. Shortly after this, a hyperechoic fistula tract was observed connecting the duodenal wall to the gallbladder wall (●" Video 1). The patient underwent cholecystectomy with fistula section and closure of the duodenal fistula orifice. Pathological ex- amination revealed chronic inflammation of the duodenal mucosa that was ad- herent to the gallbladder wall, including an acute necrohemorrhagic inflammatory process with perforation and fibrosis related to intramural lithiasis. The pa- tient’s recovery after surgery was unre- with enterobiliary fistulas are nonspecif- M. Velosa1,2, S. Lopes1,3, R. Castro4, markable and 2 months after the proce- ic, with presenting features often includ- G. Macedo1,3 dure he had gained 4kg. ing abdominal pain, nausea, weight loss, 1 Serviço de Gastrenterologia, Hospital Spontaneous enterobiliary fistula is a and obstruction of the small bowel or S. João, Porto, Portugal complication that is typically associated colon by the gallstone. Recurrent episodes 2 Serviço de Gastrenterologia, Hospital This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. with gallstones (90%) [1]. It has also been of untreated cholecystitis caused by stone Dr. Nélio Mendonça, Funchal, Madeira, ’ reported with abdominal trauma, Crohn s obstruction of the cystic duct can produce Portugal disease, peptic ulcer disease, and malig- adhesions between the gallbladder and 3 Serviço de Gastrenterologia, Faculdade nancies of the biliary tract, bowel, and bowel, as in this case [4]. Most reported de Medicina da Universidade do Porto, pancreas [2,3]. The symptoms associated cases are identified intraoperatively dur- Porto, Portugal ing laparoscopic surgery. In this case, pre- 4 Serviço de Imagiologia, Hospital S. João, operative diagnosis was possible using Video 1 Porto, Portugal luminal contrast-enhanced EUS. Contrast-enhanced endoscopic ultrasound (EUS) demonstrating a hyperechoic fistula tract Endoscopy_UCTN_Code_CCL_1AF_2AF between the duodenum and the gallbladder wall after instillation of luminal contrast. Competing interests: None Velosa M et al. Cholecystoduodenal fistula diagnosed with contrast-enhanced EUS… Endoscopy 2013; 45: E18–E19 Cases and Techniques Library (CTL) E19 References Bibliography Corresponding author 1 Noskin EA, Strauus AA, Strauss FF. Sponta- DOI http://dx.doi.org/ M. Velosa, MD neous internal biliary fistula: a review of lit- 10.1055/s-0032-1326112 Caminho dos saltos n. 32 erature and report of two cases. Ann Surg Endoscopy 2013; 45: E18–E19 Vilas jardins d’agua, moradia D 1949; 130: 270 © Georg Thieme Verlag KG 9050-219, Funchal 2 LeBlanc KA, Barr LH, Rush BM. Spontaneous Stuttgart · New York Madeira Island biliary enteric fistulas. South Med J 1983; ISSN 0013-726X Portugal – 76: 1240 1253 Fax: +351-291-572538 Yamamoto T Abe K Anjiki H 3 , , et al. Choledo- [email protected] choduodenal fistula associated with recur- rent peptic ulcer. J Med Cases 2012; 3: 243–246 4 Hession PR, Rawlinson J, Hall JR et al. The clinical and radiological features of chole- cystocolic fistulae. Br J Radiol 1996; 69: 804–809 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Velosa M et al. Cholecystoduodenal fistula diagnosed with contrast-enhanced EUS… Endoscopy 2013; 45: E18–E19.