Resident Methodist Dallas Medical Center Dallas, TX
Elizabeth S. John, MD, David S. Braun, MD, Paul R. Tarnasky, MD; Methodist Dallas Medical Center, Dallas, TX
Introduction: Enterobiliary fistulas were first described in 1654 with 68% of cases occurring between the gallbladder wall and duodenum. Choledochoduodenal fistulas (CDF) are less common (8.6%) and most are asymptomatic. This case highlights a rare presentation of pneumobilia, cholangitis, and pyogenic hepatic abscesses in a patient with CDF.
Methods: A 68 year old male with a past medical history of diabetes presented with rigors and fevers for one day. He denied abdominal pain, history of gallbladder disease, or recent travel history. Vitals signs were notable for BP 70/40, HR 110, T 101 F. Physical exam was remarkable for scleral icterus, but no abdominal tenderness or altered mentation. Lab results revealed WBC 31,000, creatinine 3.94, total bilirubin 9.6, direct bilirubin 7.9, AST 117, ALT 94, ALP 484, lactate 7.4, and positive blood cultures for Escherichia coli. CT abdomen without contrast revealed marked intra and extrahepatic bile duct dilatation with multiple focal densities identified in the liver and pneumobilia at the level of the distal common bile duct (CBD) (Fig 1). Antibiotics were started and he underwent ERCP which revealed a suprapapillary CDF with significant stone burden and pus in the CBD. Sphincterotomy was performed to the level of the CDF. Many stones were removed and two plastic stents were placed to ensure drainage. Follow up liver MRI revealed numerous hepatic abscesses. The patient’s vitals and laboratory markers improved with antibiotics, and he was scheduled for follow up outpatient ERCP to complete endotherapy. Discussion: CDF can be caused by choledocholithiasis, duodenal ulcers, tumor invasion, or post-cholecystectomy complications. Most cases of CDF are asymptomatic and incidentally detected. However in the subset of symptomatic cases, cholangitis is the most common presentation. Furthermore, chronic cholangitis due to reflux of duodenal contents with bacterial flora may cause hepatic abscesses, though this has only been documented in case reports. Diagnosis can be achieved by ERCP with direct visualization of CDF and successful cholangiography through the papilla and fistula orifice. With few studies investigating this entity, proposed treatment options are conflicting. Some advocate for less invasive measures, such as endoscopic interventions for asymptomatic patients or distal CDF. Others regard CDF as a biliary abnormality that predisposes to recurrent infections and increases the risk for malignancy, and thus advocate for surgical management.
This sagittal view of a noncontrast CT abdomen/pelvis delineates hepatic abscesses, pneumobilia at the level of the choledochoduodenal fistula, and dilated intra and extrahepatic bile ducts.
Disclosures: Elizabeth John indicated no relevant financial relationships. David Braun indicated no relevant financial relationships. Paul Tarnasky indicated no relevant financial relationships.