AB190. 162. An unusual presentation of cholecystoduodenal fistula: massive upper GI bleeding: case report

Abstract: Cholecystoenteric fistula is rare complication of gallstone disease with reported incidence of 3–5%. Cholecystoduodenal fistula (CDF) is most common biliary-enteric fistula clinical presentation is variable. Massive upper GI bleeding, caused by CDF, is very rare with only few cases reported in the literature. A 73-year-old male presented to emergency room with hemorrhagic shock with upper GI bleeding. His co-morbidities include hypertension and hyperchlostremia and cholelithiasis. He had recent left sided hip replacement. He was resuscitated with massive blood transfusion. His gastroscopy showed ulcer at D1 in diverticulum with a clot with no evidence of active bleeding. We performed CT scan of abdomen and pelvis with arterial and 90 seconds delayed phase. The study was negative for active hemorrhage in the stomach, duodenum and small bowel. There was marked stranding adjacent to the gastric antral region and first and second part of duodenum. The incidental finding was large air fluid level within the thin wall gallbladder. He continued to have malena and decided to have repeat gastroscopy. The second gastroscope showed large clot in D1 with bleeding from underneath the clot, injected and clipped but unable to control bleeding. The immediate decision to perform laparotomy. The laparotomy finding showed omentum adherent to the thickened gallbladder and D1, fistula between hartman’s pouch of gallbladder and D1 and large blood clot in the gallbladder. So he underwent partial cholecystectomy with repair of D1 fistula and gastrojejunostomy. The postoperative period was uneventful and he was discharged home on Day 16. Here we discuss the case of a 73-year male who presented with massive upper gastrointestinal (GI) bleeding due to CDF. The patient was diagnosed promptly and underwent successful emergent operation. Biliary-enteric fistula is rare with reported incidence of 3–5% in patients with cholelithiasis. The presentation of these fistulas with upper GI Bleeding is extremely rare. The gastroscopy and CT scan might enable to prompt diagnosis.

Keywords: Biliary-enteric fistula; cholecystoduodenal; upper gastrointestinal haemorrhage