Neal D. Dharmadhikari, MD1, Breton Roussel, MD1, Daniel Piascik, MHS, PA-C2, Alyn L. Adrain, MD3
1Brown University, Providence, RI; 2Gastroenterology Associates, Inc., Providence, RI; 3Warren Alpert Medical School of Brown University, Providence, RI
Introduction: Cholecystoduodenal fistulas are rare communications between the gallbladder and duodenum. Though they are most often formed as a complication of cholelithiasis, duodenal ulcers are a less common etiology of bilioenteric fistulas. This case report shows this rare finding diagnosed with direct visualization by endoscopy.
Case Description/Methods: A 75-year-old man with a medical history of atrial fibrillation, remote alcohol abuse, and diabetes presented with anemia. On presentation, his blood pressure was 92/45 and other vital signs were stable. A rectal examination revealed hematochezia and melena. His workup revealed a hemoglobin of 5.6 g/dl, BUN 64 mg/dl, and creatinine 3.76 mg/dl. He was appropriately resuscitated with blood transfusions. An endoscopy showed esophagitis and a non-bleeding cratered duodenal ulcer with pigmented material in the first part of the duodenum. This ulcer appeared to have several fistulous openings into another structure with bridges of tissue in between. A CT and an MRCP confirmed a duodenal ulcer with cholecystoduodenal fistula. He was treated conservatively with proton pump inhibitors (PPI) and had planned outpatient follow-up with surgery and gastroenterology.
Discussion: Endoscopy is the diagnostic gold standard for peptic ulcer disease (PUD) and is indicated in patients presenting with anemia and clinical evidence of gastrointestinal bleed. Cholecystoduodenal fistulas are an extremely rare complication of PUD. Unlike this case, most bilioenteric fistulas form as a consequence of gallbladder pathology, such as complications of cholecystitis or cholelithiasis, rather than PUD. Furthermore, this case is unusual in that bilioenteric fistulas are most often diagnosed by imaging rather than endoscopic visualization. This patient likely had chronic PUD that caused perforation and the eventual formation of the fistula. Uncomplicated cholecystoduodenal fistulas are often asymptomatic which can make them difficult to diagnose. Conservative management with PPIs is the preferred treatment for PUD-related bilioenteric fistulas and this patient was ultimately discharged on PPI therapy with outpatient follow up. This case highlights a unique endoscopic finding of a cholecystoduodenal fistula in a patient who presented without any complaints and found to have anemia and PUD. In addition, it supports PPIs as a conservative treatment for bilioenteric fistulas secondary to PUD.
Citation: Neal D. Dharmadhikari, MD; Breton Roussel, MD; Daniel Piascik, MHS, PA-C; Alyn L. Adrain, MD. P0041 - CHRONIC PEPTIC ULCER DISEASE RESULTING IN CHOLECYSTODUODENAL FISTULA. Program No. P0041. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.