Abstract
This report is concerned with studies on sixteen cases of a spontaneous choledochoduodenal fistula with an orifice at the major papilla which were preoperatively diagnosed ' by an endoscopic observation and retrograde pancreatocholangiography. Followings are the summaries.1) These fistulae were divided into three types. Type I has an orifice just proximal to the normal bile duct opening of the major papilla, whereas type B at the longitudinal fold and type III just proximal to the longitudinal fold. Endoscopic appearance of the orifice enabled us to divide these fistulae into two groups : freshly formed fistulae and old ones. The former were noted as soft granulation tissue with inflammatory reaction and no epithealial covering yet. The latter were noted as wide openings with epithelial covering and no inflammatory reaction Our data suggest that the former types heal to close or to form the latter type of openings in four to nine months. Ten of the sixteen cases showed the latter type of opening, suggesting of difficulty encountered by the fistulae to close.2) Incidence was high in female and in the population over fifth decade.3) Twelve of the sixteen cases had a history of gall stones over three years.4) Thirteen cases showed a triad of abdominal pain, jaundice and spiking fever. Thirteen cases showed a characteristic clinical episode to suggest a formation of the fistula. Time-lapse between the characteristic episode and an endoscopic examination was one month to fourteen years.5) Air or barium in the biliary tract was revealed in six cases on X-ray examination 6) It was emphasized that a cannule should be inserted with a strong bent upward through the fistula to obtain a satisfactory retrograde cholangiography.7) It was suggested that presenting symptoms were caused by ascending cholangitis in two cases, necessitating some surgical intervention to prevent such an ascending infection.8) No cases showed any deterioration in liver functin test during the follow-up periode ranging from one to twenty-four months.9) It was proposed that this type of fistula would not be so rare as to be estimated by a scarcity of re ported cases and that more cases would be f ould in future by a careful duodeno-fiberscopic examination. This type of fistula may be revealed in some of cases which were reported as insufficiency of sphincter of Oddi.
