1976 Volume 18 Issue 3 Pages 472-477
This report concerns a case of spontaneous cholecystduodenal fistula with interesting endoscopic findings and clinical course. The patient, 62 years old man, visited our out patient department with chief complaints of hematemesis and right upper abdominal pain. Endoscopic examination which was promptly performed with Olympus GIF-D2 in order to spot the site of bleeding revealed a small amount of hemarrhage in the duodenal bulb and a large dark brown gall stone just coming out of a large orifice of the cholecystduodenal fistula at the anterior wall of the duodenal bulb. An attempt at an endoscopic removal of the gall stone was unsuccessful due to it's huge size. The patient was admitted for a close observation of the clinical course because the possibility of a developement of complications such as gall stone ileus and massive hemorrhage was considered. A flat film of the abdomen revealed a large amount of air in the duodenal bulb communicating with the gall bladder and intrahepatic and extrahepatic bile duct. Symptoms suggestive of gall stone ileus developed on 4th hospital day and an operation was performed on 5th day. A large bullet-shaped stone, 22×24×40mm in size, was removed from the ileum, 30cm proximal to the ileocoecal junction. Remaining of other gall stones was considered from the facet formation seen at one end of the removed stone, but surgical intervention to the biliary tract was abandoned because of acute inflammatory changes of the region and the patient's general condition. No other stones were palpable, however, in the gastrointestinal tract. The postoperative course had been uneventful until 9th day, when symptoms suggestive of gall stone ileus recurred. Medical treatment resulted a passage of a large stone, ctimes;2122mm in size, in the stool on 17th day. The second endoscopic examination performed cn 30th day revealed complete healing and closure of the fistula orifice resulting in a scar formation at the anterior wall of the duodenal bulb. Endoscopic retrograde cholangiography showed moderate dilatation of the bile duct and deformity of the gall bladder without any residual gall stones or an abnormal communication between the biliary tract and the duodenum. Outflow of the contrast material through the Vaterian bile duct was normal. No air was shown in the biliary tract. The third endoscopic examination performed 4 months later showed similar findings. Clinical course of the patient has been uneventful. This case indicates an importance of a flat film of the abdomen and suggests that a spontaneous internal biliary fistula can heal to close completely in a short period in a case in which a couse of obstruction of the biliary tract distal to the fistula is removed.
