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      Common bile duct stones: an unusual case of diarrhoea through a mucous fistula

      case-report

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          Abstract

          We present a very unusual case of diarrhoea in a 77-year-old man. He had a previously complicated surgical history, with a loop ileostomy and a colonic mucous fistula. He developed a sudden onset of diarrhoea from his mucous fistula. A contrast enema suggested a cholecystocolonic fistula and subsequent computed tomography demonstrated a common bile duct stone caused a degree of obstruction. The patient was treated successfully by endoscopic retrograde cholangiopancreatography and stone extraction. This case demonstrated the role that contrast enema may still play in unusual cases of diarrhoea.

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          Cholecystocolonic fistula: facts and myths. A review of the 231 published cases.

          Bertrand Dousset, Leopoldo Sarli, Vincenzo Violi … (2008)
          Cholecystocolonic fistula (CCF) is the second most common cholecystoenteric fistula and is often discovered intraoperatively, resulting in a challenging situation for the surgeon, who is forced to switch to a complex procedure, often in old, unfit patients. Management of this uncommon but possible finding is still ill defined. An extensive review of 160 articles published from 1950 to 2006 concerning 231 cases of CCF was performed. CCF is mostly an affliction of women in their sixth to seventh decades and is rarely diagnosed preoperatively. Chronic diarrhea is the key symptom in nonemergency patients, but, in one-fourth of cases, CCF presents with an acute onset, mostly biliary ileus. In one-fourth of patients, a second hepatobiliary abnormality is present, including gallbladder cancer in 2% of cases. In uncomplicated cases, diverting colostomy is not performed anymore, and laparoscopy treatment has been described in specialized centers. Symptomatic treatment of concomitant biliary ileus (without treating CCF) is a feasible option. Resolution of colonic biliary ileus by interventional endoscopy is reported. CCF should be considered in differential diagnosis of diarrhea, especially in old, female patients. A possible second hepatobiliary abnormality should be always investigated. Extemporaneous frozen section should be performed if gallbladder cancer is suspected. Depending on clinical presentation, different treatments for CCF are indicated, ranging from minimally invasive procedures to extensive resection.
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            Biliary enteric fistula.

            F Glenn, John C. Reed, Marjorie Grafe (1981)
            From 1932 to 1978, 105 patients with biliary enteric fistulas are reported upon from The New York Hospital-Cornell Medical Center. During this 46 year period, 11,808 patients were operated upon for nonmalignant biliary tract disease, representing an incidence of biliary enteric fistulas of 0.9 per cent. The most common location of the fistula was cholecystoduodenal in 77 per cent and cholecystocolic in 15 per cent. Ninety-eight of the 105 patients underwent 109 surgical procedures for symptoms and complications associated with the fistula. The operative mortality was 6 per cent. The recommended definitive procedure includes cholecystectomy, excision of the fistula, common bile duct exploration and operative cholangiography. Among the 105 patients were 22 who presented with intestinal obstruction or ileus due to gallstones. The operative mortality in this group was 4.5 per cent. The recommended treatment for this condition is operative relief of the obstruction with correction of the biliary enteric fistula at an elective second stage operation.
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              Cholecystocolocutaneous fistula: a case report.

              Peter A Wyman, M Shrestha (2006)
              Cholecystocolocutaneous fistula (CCCF) is a rare complication of gallstone disease resulting from spillage of gallstones from perforation of an empyema of the gallbladder, which can pose diagnostic dilemmas. We describe a patient, who presented initially with a swelling followed by discharging sinuses on her right flank where a diagnosis of CCCF was made and was treated surgically with satisfactory outcome. A computed tomography (CT) scan showed an ill-defined soft tissue mass in the right subhepatic space and a fistulogram demonstrated passage of contrast into the gallbladder fossa and hepatic flexure of colon. At laparotomy, a cutaneous fistula containing two pigment stones led to the gallbladder fossa and hepatic flexure of colon. Debridement of infected granulation tissues which had replaced the gallbladder, closure of the cystic duct stump and colonic fistula followed by excision of the fistula tract led to complete resolution. CCCF is a rare complication of perforated gallbladder with spillage of calculi, and a fistulogram is helpful in establishing the diagnosis. This case highlights the importance of retrieving spilled stones following interventions in the gallbladder to prevent the complication.
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                Author and article information

                Contributors
                PT Davey
                Journal
                Journal ID (nlm-ta): Ann R Coll Surg Engl
                Journal ID (iso-abbrev): Ann R Coll Surg Engl
                Journal ID (publisher-id): bulletin
                Title: Annals of The Royal College of Surgeons of England
                Publisher: Royal College of Surgeons
                ISSN (Print): 0035-8843
                ISSN (Electronic): 1478-7083
                Publication date (Print): October 2012
                Publication date (Electronic): October 2012
                Publication date PMC-release: October 2012
                Volume: 94
                Issue: 7
                Pages: e221-e222
                Affiliations
                Southern Health and Social Care Trust,UK
                Author notes
                34 The Boulevard, Belfast BT7 3LN,UK E: phildavey@ 123456doctors.net.uk
                Article
                Publisher ID: 384936
                DOI: 10.1308/003588412X13373405384936
                PMC ID: 3954265
                PubMed ID: 23031755
                SO-VID: 45a910ea-e384-4ae1-9d65-150d0beaafd1
                Copyright © Copyright © 2013 Royal College of Surgeons
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date accepted : 08 August 2012
                Categories
                Subject: Online Case Report

                Keywords: gallstones,cholecystocolonic fistula,diarrhoea
                Data availability:
                Keywords: gallstones, cholecystocolonic fistula, diarrhoea

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