Muhammad Farhan Ashraf, MBBS, Haider Rahman, MD, Rosa Bui, MD, Omar Tageldin, MD, Domenico Viterbo, MD; Albany Medical Center, Albany, NY
Introduction: A choledochoduodenal fistula (CDF) is defined as an anomalous pathway between the common bile duct and duodenum. It is a rare condition usually found incidentally on endoscopic examination. The most common cause is the longstanding choledocholithiasis. We present the case of a 76-year-old male with an interesting presentation of such fistula.
Methods: A 76-year-old male was transferred to our hospital after he was found to have fevers, elevated LFTs, and blood cultures positive for E.Faecalis. The patient had a past medical history of cholecystectomy and colostomy after colon perforation. On admission, he had a white cell count of 13300. A CT scan showed pneumobilia, intrahepatic ductal dilation, and multiple liver abscesses, the largest measuring 5.5 x 4.5 x 3.9 cm in segment VII. A pigtail catheter was placed to drain the main abscess and aspirate culture grew E.Faecalis, Candida, and E. Faecium. The patient was started on IV antibiotics. Due to concern for malignancy with bacterial translocation, a colonoscopy was performed. This was unrevealing. Further investigation regarding the source of bacteremia led to an MRCP. This showed a distal CBD lesion with concern for retained stone and a questionable choledochal cyst. An EGD/ERCP was performed. This revealed an impacted stone in the mid-distal CBD that had eroded into the posterior duodenal wall. The stone was removed with Spyglass/electrohydraulic lithotripsy and a balloon sweep. A surgical evaluation was obtained but the patient was deemed too high risk for any intervention. The patient’s LFTs eventually trended down and an interval CT scan showed a decrease in the size of the abscess.
Discussion: Choledochoduodenal fistulas are classified as either proximal or distal. Proximal are present more than 2 cm away from the ampulla and drain along the posterior duodenal bulb. Distal types drain around the peri-ampullar area. CDFs greatly increase the risk of ascending biliary infections and bacteremia. Hepatic abscesses are an additional complication. Pneumobilia can be seen in these patients along with intrahepatic ductal dilation. Management is mainly surgical for patients with proximal CDFs due to a high recurrence of infection.
Choledocholithiasis eroding into duodenal bulb forming a choledochoduodenal fistula
EHL with fragmentation of choledocholithiasis
Choledochoduodenal fistula with visible lumen of CBD after stone removal
Disclosures: Muhammad Farhan Ashraf indicated no relevant financial relationships. Haider Rahman indicated no relevant financial relationships. Rosa Bui indicated no relevant financial relationships. Omar Tageldin indicated no relevant financial relationships. Domenico Viterbo indicated no relevant financial relationships.