Henry Ford Macomb Hospital Clinton Township, MI, United States
Award: Presidential Poster Award
Rita Rehana, MD, Rene Peleman, MD, Asim Shabbir, MD Henry Ford Macomb Hospital, Clinton Township, MI
Introduction: Cholecystocolic fistula is a rare form of biliary-enteric fistulae that typically form between the gallbladder and hepatic flexure. Patients usually present with atypical symptoms, especially in elderly. Subtle signs and symptoms, such as abdominal pain and diarrhea are most frequently associated with chronic onset of cholecystocolic fistulas. In high risk patients, depending on the gallstone location, retrieval is accomplished by endoscopy. Despite modern diagnostic tools, this condition can be missed. Therefore, we focus our case on the unpredictability of gallstones and its gastrointestinal complications.
Case Description/Methods: We present an 80 year old woman without medical history who complained of epigastric pain for 1 day. She initially identified the pain as heartburn that later developed in the right lower abdomen with radiation to the left. She endorsed nausea and emesis. On admission she was afebrile, exam revealed diffusely tender abdomen. Labs were significant for leukocytosis of 14.9 K/uL and normal liver enzymes. Acute abdominal series showed pneumobilia and ileus. HIDA scan revealed findings of a fistulous tract between the gallbladder and hepatic flexure of the colon with cystic duct patency. CT abdomen confirmed the fistula and location and also noted a 3 cm wide gallstone within the hepatic flexure. Gastroenterology was consulted for further evaluation with colonoscopy which showed an obstructed colon at the hepatic flexure from a gallstone with ischemic mucosal changes requiring surgical intervention. Patient was taken for exploratory laparotomy revealing a large mobile mass within the transverse colon. Colotomy was done to remove a massive gallstone; this was also used to identify the cholecystocolic fistula, which was confirmed by an intraoperative cholangiogram. Surgical intervention was successful.
Discussion: In less severe cases, symptoms can be aspecific and preoperative diagnosis often fails to show such a rare condition. Fortunately in this case, diagnostic imaging was able to find the source and achieve a diagnosis prior to surgery. Most of these cases are identified incidentally during cholecystectomy. The acuity of this case makes it high risk for biliary sepsis due to the cholecystocolic fistula communicating with an intestinal lumen, a site with very high bacterial load. This case demonstrates the collaborative intervention of subspecialties and importance of endoscopic evaluation along with contemporary diagnostic methods prior to surgical intervention.
Figure: Image A: Gross transverse colon with gallstone extraction measuring about 8 cm in length. Image B: CT abdomen demonstrating a fistulous truncation between the gallbladder and hepatic flexure (green arrow) of the colon and gallstone within the hepatic flexure (red & blue arrow). Image C: HIDA scan confirmed activity seen draining into the fistulous tract (arrow) between the gallbladder and hepatic flexure of the colon.
Rita Rehana indicated no relevant financial relationships.
Rene Peleman indicated no relevant financial relationships.
Asim Shabbir indicated no relevant financial relationships.
Rita Rehana, MD, Rene Peleman, MD, Asim Shabbir, MD. P2287 - Large Bowel Obstruction Caused by Massive Gallstone, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.