CT FINDINGS OF CHOLECYSTOGASTRIC FISTULA

Posted Mon, 01/25/2010 - 13:50 by husam wahbeh
Images

FIGURE 1

FIGURE 2

FIGUER 3

FIGURE 4


Clinical History:

A 71 years old male patient referred to our hospital with weight loss ;indigestion; epigastric pain ;nausea and vomiting .The physical examination revealed epigatric and peri umbilical tenderness .The complete blood count was normal .Tumor markers showed an increase in CA 19-9 (214.9) normal value is( 0 -39 );CA 72-4 (38.4 ng/L) and CEA was 8.54 ng / L . Liver function test were increased: GGT 328 u/L (5-40); AST 162 u/L (8-33); ALT 112 u/L (5-40) and ALP 957 u/L (35-129). An upper gastrointestinal tract endoscopy showed a necrotic exudative mass in the pylorus and the antrum of the stomach. The histopathological examination showed a gastric adenocarcinoma. IV and orally enhanced abdominal CT scan was performed .


Findings:

figure 1 axial abdomen CT scan showing dilatation of the intrahepatic bile ducts
figure 2;3;4 axial and coronal reformat showing thicked stomach and gall bladder
walls with passage of the orally ingested contrast from stomach to gall bladder demonstrating a cholecystogastric fistula


Diagnosis:

GASTRIC ADENOCARCINOMA CASUSING A CHOLECYSTOGASTRIC FISTULA


Discussion:

The cholecystogastric fistulas are rare compared to cholecysotoduodenal and cholecystocoic fistulas. Most of these fistulas are caused by acute cholecystitis.However trauma ; Crohn s disease; ulcerative colitis; gastrointestinal tract and pancreatic malignancies are among the other causes.

In chledochal fistulas a calculus may pass to small bowel resulting in intestinal obstruction. The patient may suffer from dyspepsia; abdominal pain; malabsorbtion and diarrhea. Cholangitis and peritonitis are important complications of these fistulae.
Abdominal plain film; USG; barium studies; biliary scintigraphy and ERCP are used for diagnosis. Plain films and barium studies show gas and barium in the gall bladder and the biliary tree.Knowing the underlying cause of the fistula plays an important role in its treatment.In this case we showed cholecystogastric fistul using orally and iv enhanced abdominal CT.
Presence of biliary air and presence of a calculus resulting in small bowel obstruction are diagnostic of these fistulae.
Symptomatic cases are treated by cholecysectomy and closure of fistula.


References / Suggested Reading:

1-Cuschieri A, Grace PA, Darzi A, Borley N, Rowley DI (eds). Disorders of biliary tract. Blackwell Publishing Hong Kong, 2003:355.
2-Reisner RM. Gall stone ileus: a review of 1001 reported cases. Am Surg 1994;60:441.
3-Afflerbaugh JK Cole HA 1995 Intragastric gallstone.Radiology 64:581-583 2. Hession PR, Rawlinson J, Hall JR, Keating JP, Guyer PB. The clinical
and radiological features of cholecystocolic fistulae. Br J Radiol
1996;69:804-9.
4-LeBlank KA, Barr LH, Rush BM. spontaneous biliaryenteric fistulas.
South Med J 1983;76:1248-52.
5-Elsas LJ, Gilat T. Cholecystocolonic with malabsorption. Ann Intern
Med 1965;63:481-6.
6- Swinnen L, Sainte T. Colonic gallstone illeus. J Belge Radiol
1995;77:272-4.
7- Hession PR, Rawlinson J, Hall JR, Keating JP, Guyer PB. The clinical
and radiological features of cholecystocolic fistulae. Br J Radiol
1996;69:804-9.
8. LeBlank KA, Barr LH, Rush BM. spontaneous biliaryenteric fistulas.
South Med J 1983;76:1248-52.


Author

HUSAM Wahbeh,MD

Radiology Resident

HACETTEPE UNIVERSITY HOSPITAL ANKARA TURKEY

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Thu, 01/28/2010 - 09:39
#1
Nursel Yurttutan
Nursel Yurttutan's picture
User offline. Last seen 22 weeks 5 days ago. Offline
Joined: 01/25/2010
A very good case..Thank you

A very good case..Thank you very much

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Wed, 01/27/2010 - 13:29
#2
yakup yeşilkaya
yakup yeşilkaya's picture
User offline. Last seen 26 weeks 2 days ago. Offline
Joined: 12/10/2009
Good case! Thank you Dr.Hüsam

Good case! Thank you Dr.Hüsam Wahbeh.

Dr.Yakup YEŞİLKAYA

Hacettepe Medical School Department of Radiology ANKARA

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Tue, 01/26/2010 - 07:00
#3
Vikram Dogra
Vikram Dogra's picture
User offline. Last seen 20 hours 18 min ago. Offline
Joined: 05/23/2007
Excellent case. This is very

Excellent case. This is very unusual case. Choledocho- duodenal fistula's are very rare and this case is probably the first in the literature. Thank you for your submission and sharing this case with everyone.

Dr. Vikram Singh Dogra

Professor of Radiology, Urology & BME
Associate Chair for Education and Research.
Department of Imaging Sciences
University of Rochester School of Medicine

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