Nicholas Talabiska, DO1, Christopher Pluskota, DO2, Bradley Confer, DO2 1Temple University, Philadelphia, PA; 2Geisinger Health System, Danville, PA
Introduction: Cholecystocolonic fistulas (CCF), although rare, are most commonly a sequelae of chronic gallstone disease. Other etiologies include trauma, abdominal surgery and neoplastic disease. Regardless of etiology, inflammation within the gallbladder leads to formation of adhesions with adjacent structures. Subsequently longstanding inflammation and pressure necrosis eventually leads to fistula formation. Herein, we describe a case of an asymptomatic CCF discovered during colorectal cancer (CRC) surveillance via colonoscopy.
Case Description/Methods: A 69-year-old male presented for high-risk CRC surveillance colonoscopy. History was significant for morbid obesity. A fistula was found in the proximal transverse colon with obvious purulent drainage. There were no signs of inflammatory bowel disease (excluded on pathology), however, the colon appeared fixed in this region. CT abdomen/pelvis with IV and oral contrast confirmed a fistulous connection between the right transverse colon and gallbladder with focal gallbladder wall thickening, pericholecystic inflammatory changes and concern for abscess formation between the gallbladder and hepatic margin. Laparoscopic cholecystectomy with intra-operative colonoscopy was scheduled for possible fistula tract closure. The gallbladder was successfully removed laparoscopically with 3 cm stone found adherent to the posterior gallbladder/proximal transverse colon. Upon removal, an ulcerated fistula was revealed. Colonic disruption was confirmed intraoperatively by an underwater leak test. Due to tract size of > 20 mm, it was decided that endoscopic tract closure would not be successful. Significant surrounding edema prompted conversion to a successful open segmental colectomy. The patient tolerated the procedure well with no post-op complications.
Discussion: This case is interesting in that despite having a large CCF with developing abscess the patient remained asymptomatic. Patients with undiagnosed tracts are most commonly symptomatic with diarrhea and/or right upper quadrant abdominal pain. More severe complications include obstruction, bleeding, and abscesses. Additionally, this CCF was identified during routine screening colonoscopy compared to the typical intraoperative discovery. Ultimately, the importance of early diagnosis of CCFs is two-fold: (1) to decrease patient morbidity and mortality; (2) proper surgical/endoscopic staging to alleviate intraoperative burden and reduce health care system expenditures.
Disclosures: Nicholas Talabiska indicated no relevant financial relationships. Christopher Pluskota indicated no relevant financial relationships. Bradley Confer: Boston Scientific – Consultant. Merit Endotek – Consultant.
Nicholas Talabiska, DO1, Christopher Pluskota, DO2, Bradley Confer, DO2. P2131 - Encountering an Unusual Tract During Colorectal Cancer Surveillance in an Asymptomatic Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
