Hepatobiliary and Pancreatic: Spontaneous cholecystocutaneous fistula

Abstract

An 86-year-old male presented to the emergency department with pain and swelling in the right upper quadrant (RUQ). He was afebrile and not jaundice. Blood routine test demonstrated an elevated white blood cell of 9900/mm, with 10.7% monocytes. Urine amylase was 882 U/L. Abdominal examination revealed a 5 × 5 cm abscess in the subcostal area, surrounded by soft tissue cellulitis (Fig. 1b). The abdominal ultrasound examination revealed gallstones. For further diagnosis and treatment, the patient underwent an abdominal computed tomography (CT) (Fig. 1a), which showed a perforation of the gallbladder fundus, causing a localized abscess between the gallbladder and the abdominal wall. Thus, he was admitted to hospital for calculous cholecystitis and gallbladder perforation. Magnetic resonance imaging (MRI) detected gallstones, gallbladder perforation, and sinus tract formation between gallbladder and right abdominal wall (Fig. 1c). Cholecystectomy and abscess drainage were performed. There was marked inflammation wrapped around the gallbladder, which was closely adhered to the surrounding tissue, such as liver, greater omentum, and transverse hepatic flexure. The gallbladder was full of stones and pus (Fig. 1d). We opened the abscess, removed the necrotic tissue, rinsed the purulent cavity, closed the fistula from the abdominal cavity, and packed the cavity with iodoform gauze. Antibiotics were given according to the microbiological test. The drainage incision was sutured on the seventh day after the operation. The patient was discharged 3 days later. Histopathological analysis demonstrated chronic cholecystitis and adenomyomatosis of gallbladder. Spontaneous cholecystocutaneous fistula is a rare complication of neglected gallbladder disease. Spontaneous cholecystocutaneous fistula was first described by Thilesus in 1670. Only 28 cases were published over the last 10 years. With the advances in radiology, the disease can be diagnosed easily and early. Antibiotic therapy and surgery are effective treatment, leading to a good prognosis. The perforation of gallbladder jeopardizes neighboring organs, such as colon, duodenum, and stomach, which can result in formation of internal fistulas. External biliary fistula is rare and can be a postoperative complication of liver and biliary tract surgery, traumatic, therapeutic, or spontaneous. Increased pressure in the gallbladder and the cystic duct obstruction, mostly caused by calculus cholecystitis or occasionally due to gallbladder carcinoma, is the likely the underlying cause of cholecystocutaneous fistula. The fistula usually occurs via the fundus of the gallbladder, as this is the farthest from the cystic artery and most likely to be affected in inflammation-caused ischemia. Cholecystocutaneous fistula is characterized by chronic gallbladder perforation. Although cholecystocutaneous fistula is now a rare complication of gallbladder disease, we should take into account the possibility of this complication when it comes to unexplained abdominal wall abscess.