Overview
Definition:
A cholecystoenteric fistula is an abnormal communication between the gallbladder and a segment of the gastrointestinal tract, most commonly the duodenum or jejunum
Takedown refers to the surgical procedure aimed at closing this abnormal tract, often in conjunction with management of the underlying cause (e.g., gallstones).
Epidemiology:
While exact incidence is difficult to ascertain due to varied reporting, cholecystoenteric fistulas are a known complication of chronic cholecystitis and cholelithiasis, occurring in approximately 0.1% to 0.5% of patients with gallstones
They are more common in elderly individuals with prolonged, symptomatic gallstone disease.
Clinical Significance:
These fistulas can lead to significant morbidity, including recurrent cholangitis, cholecystitis, biliary sepsis, malabsorption, nutritional deficiencies, and the passage of gallstones into the GI tract (leading to gallstone ileus)
Definitive surgical intervention is often required to prevent recurrent complications and improve patient outcomes.
Clinical Presentation
Symptoms:
Right upper quadrant pain
Epigastric discomfort
Recurrent episodes of cholecystitis or cholangitis
Intermittent jaundice
Nausea and vomiting
Diarrhea or malabsorption
Passage of gallstones in stool
Symptoms of gallstone ileus, such as abdominal distension, obstipation, and colicky abdominal pain.
Signs:
Tenderness in the right upper quadrant or epigastrium
Palpable abdominal mass or distension in cases of obstruction
Fever and signs of sepsis
Icteric sclera and skin if biliary obstruction is present.
Diagnostic Criteria:
Diagnosis is typically made based on a combination of clinical suspicion and imaging findings
While no specific formal diagnostic criteria exist, a high index of suspicion in patients with a history of complicated gallstone disease presenting with recurrent GI or biliary symptoms is paramount
Imaging showing the abnormal connection is definitive.
Diagnostic Approach
History Taking:
Detailed history of gallstone disease, previous cholecystitis or cholangitis episodes
Duration and pattern of abdominal pain
Presence of jaundice, fever, or diarrhea
Symptoms suggestive of gallstone ileus (obstipation, vomiting, abdominal distension)
Previous abdominal surgeries
Medications and comorbidities.
Physical Examination:
Thorough abdominal examination to assess for tenderness, guarding, rebound tenderness, masses, organomegaly, and bowel sounds
Examination for signs of jaundice and sepsis
Digital rectal examination to assess for fecal impaction or passage of gallstones.
Investigations:
Abdominal ultrasonography: May show thickened gallbladder wall, gallstones, and potentially dilatation of the common bile duct
May sometimes visualize the fistula or stones within the bowel
Computed Tomography (CT) scan: The gold standard for diagnosing cholecystoenteric fistulas and gallstone ileus
It can delineate the fistula tract, identify the involved organs, detect gallstones in the lumen, and assess for complications like bowel obstruction or perforation
Magnetic Resonance Cholangiopancreatography (MRCP): Useful for visualizing the biliary tree and identifying fistulas, though CT is often preferred for bowel involvement
Upper GI Endoscopy or Colonoscopy: May reveal gallstones in the GI tract or evidence of inflammation/stricture at the fistula site, though direct visualization of the fistula is uncommon
Laboratory tests: Complete blood count (CBC) for leukocytosis suggestive of infection
Liver function tests (LFTs) to assess for cholestasis (elevated bilirubin, alkaline phosphatase, GGT)
Amylase and lipase to rule out pancreatitis.
Differential Diagnosis:
Peptic ulcer disease
Crohn's disease of the duodenum or jejunum
Malignancy of the gallbladder or adjacent GI tract
Appendicitis (if symptoms are atypical)
Diverticulitis
Chronic pancreatitis.
Management
Initial Management:
For patients presenting with acute complications like perforation or obstruction, immediate resuscitation is crucial
This includes fluid resuscitation, electrolyte correction, pain management, and broad-spectrum antibiotics if sepsis is suspected
Nasogastric tube decompression may be required for bowel obstruction.
Medical Management:
Primarily supportive care
Antibiotics for associated cholangitis or cholecystitis
Nutritional support if malabsorption is significant
Pain management.
Surgical Management:
Surgical intervention is generally indicated for symptomatic cholecystoenteric fistulas and gallstone ileus
The goals are to relieve obstruction, close the fistula, remove the source of pathology (gallstones), and manage complications
Procedure: Laparoscopic or open surgery
Components include:
1
Enterotomy and stone extraction: For gallstone ileus, the bowel is opened, gallstones removed, and the enterotomy closed
2
Fistula closure: The fistula tract between the gallbladder and the GI tract is surgically divided and the openings on both organs are repaired, typically with sutures
3
Cholecystectomy: Removal of the gallbladder is essential to prevent recurrence
4
Possible bowel resection: If there is significant inflammation or injury to the bowel at the fistula site, a segmental resection and anastomosis may be necessary
Surgical approaches depend on patient stability, extent of disease, and surgeon expertise
Laparoscopic approaches are increasingly used for stable patients.
Supportive Care:
Postoperative care includes continued fluid and electrolyte management, adequate pain control, monitoring of vital signs and urine output, and gradual resumption of oral intake
Enteral or parenteral nutrition may be required depending on the extent of surgery and recovery
Early mobilization is encouraged.
Complications
Early Complications:
Sepsis and septic shock
Anastomotic leak from bowel or gallbladder closure
Intra-abdominal abscess formation
Bleeding
Injury to adjacent organs (e.g., portal vein, common bile duct)
Prolonged ileus.
Late Complications:
Recurrent fistula formation
Stricture at the site of fistula closure or bowel anastomosis
Cholangitis
Recurrent gallstones if cystic duct remnant is left behind or if stones form in intrahepatic ducts
Malabsorption and nutritional deficiencies.
Prevention Strategies:
Prompt diagnosis and management of symptomatic cholelithiasis and cholecystitis
Aggressive treatment of acute cholecystitis to prevent progression to gangrene and fistula formation
Careful surgical technique during cholecystectomy to avoid injury to the duodenum or jejunum.
Prognosis
Factors Affecting Prognosis:
Patient's overall health status and comorbidities
Presence and severity of complications (e.g., sepsis, perforation, bowel obstruction)
Extent of inflammation at the fistula site
Surgical approach and expertise
Presence of underlying malignancy.
Outcomes:
With timely and appropriate surgical management, the prognosis for cholecystoenteric fistulas is generally good, with significant improvement in symptoms and reduction in recurrence rates
However, mortality can be high in elderly, frail patients with severe sepsis or perforation.
Follow Up:
Postoperative follow-up typically includes clinical assessment for resolution of symptoms and surveillance for complications
Long-term follow-up may be guided by the presence of specific complications such as strictures or recurrent disease
Imaging studies may be performed as needed.
Key Points
Exam Focus:
Cholecystoenteric fistula is a complication of chronic cholecystitis/cholelithiasis
CT scan is the investigation of choice for diagnosis and planning surgical intervention
Management is surgical, involving fistula closure, cholecystectomy, and management of gallstone ileus if present
Common fistula is cholecystoduodenal.
Clinical Pearls:
Always consider cholecystoenteric fistula in patients with recurrent biliary symptoms and vague GI complaints, especially if they are elderly or have a history of complicated gallstone disease
Gallstone ileus should be suspected in elderly patients with small bowel obstruction and a history of gallstones
Plain abdominal X-ray may show Rigler's sign (two radiopaque lines: one representing the bowel wall, the other the gallstone) or air in the biliary tree (aerobilia).
Common Mistakes:
Delaying surgical intervention in the presence of complications like obstruction or sepsis
Inadequate cholecystectomy leading to recurrence
Failure to consider fistula in patients with atypical biliary or GI symptoms
Incorrect diagnosis due to reliance on a single imaging modality.