Cholecystogastric fistula

Spontaneous tract with bile flow between gall bladder and adjacent structures

1. CHOLECYSTO ENTERIC FISTULA Dr . Rabindra Tamang Junior Resident BPKIHS, Dharan Nepal

2. Contents Introduction Clinical features Diagnosis Treatment Conclusion

3. Cholecystoenteric fistula Spontaneous tract with bile flow between gall bladder and adjacent structures Rare complication Late sequelae

4. Types Cholecysto dudenal fistula Cholecystocolic fistula Cholecystogastric fistula

5. Aetiology Gall stone disease Others: malignancy of the colon , biliary system, and head of the pancreas C rohn’s disease of duodenum Peptic ulceration into GB Antonacci et; al Department of General and Emergency Surgery, University of Bologna, S. Orsola -Malpighi Hospital , Via Massarenti 9, 40138 Bologna, Italy

6. Mechanisms Inflammatory mechanism Pressure necrosis mechanism

7. Clinical presentations Symptoms of uncomplicated gall stone disease Jaundice Cholangitis Gall stone ileus Bouveret’s syndrome

8. Diagnosis Almost always an intra operative findings High degree of suspicion

9. Imaging Plain x-ray abdomen

10. Ultrasonography Pneumobilia Thick gall bladder and atrophic cholecystitis Cholelithiasis

11. CT findings Pneumobilia , Two approximated organs with an edematous wall, Pericholecystic inflammatory change , A gall stone in the gastrointestinal tract, Bowel dilatation , and direct visualization of the fistula Computed tomography demonstration of cholecystogastric fistula Chung Kuao Chou MD, MPH * Department of Radiology, Yuan’s General Hospital, No. 162, Cheng-Kung 1st Rd, Kaohsiung, Taiwan, Republic of China

12. Rigler’s triad

13. Intra op findings Dense adhesion between inflamed gall bladder and stomach.

14. Surgery Mainstay of treatment The ideal surgical treatment is still controversial

15. Enterolithotomy Extraction of stone through an enterotomy Hemodynamically unstable Significant co-morbidities

16. One stage procedure Enterolithotomy , cholecystectomy and fistula repair at a single setting Hemodynamically stable patients Decreased mortality as compared to two stage procedure G. Conzo et al Gallstone ileus: One-stage surgery in an elderly patient One-stage surgery in gallstone ileus International Journal of surgery case reports

17. Two stages procedure Enterolithotomy alone and interval cholecystectomy plus fistula repair Indications: Young patients Retained gall stones

18. Laparoscopic approach Laparoscopic surgery was contraindicated earlier Conversion of laparotomy : at any stage during operation. Frozee RC et al. What are the contraindications for laparoscopic cholecystectomy ? Am J Surg 1991;164:491–498.

19. Principle : Removal of GB and closure of fistula Laparoscopic cholecystectomy f/b Endo GIA application or hand sewn closure of fistula

20. Endoscopic management ERCP stenting and/or sphinterotomy Edward C Toll ,Michael D Kelly Successful management of cholecystocolic fistula by endoscopic retrograde cholangiopancreatography : a report of two cases

21. Conclusion Cholecystoenteric fistula may occur without obvious symptoms or signs related to chronic cholelithiasis and , In appropriate conditions, may be demonstrated definitively in a routine, readily available CT examination. Treatment is surgical and procedure is determined by the clinical status of the patient.

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