Intestinal Research 2018; 16(1): 158-159  https://doi.org/10.5217/ir.2018.16.1.158
A rare cause of gastrointestinal hemorrhage
Wei-Chen Lin1,2, and Cheng-Hsin Chu1,2
1Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan., 2MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan.
Correspondence to: Cheng-Hsin Chu, Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei 10449, Taiwan. Tel: +886-2-25433535 (ext. 2260), Fax: +886-2-25433642, mmh4071@gmail.com
Received: October 12, 2017; Revised: October 17, 2017; Accepted: October 18, 2017; Published online: January 30, 2018.
© Korean Association for the Study of Intestinal Diseases. All rights reserved.

Question:

An 88-year-old man with a 2-week history of right upper abdominal pain and fever was brought to MacKay Memorial Hospital. Physical examination revealed icteric sclera and tenderness in the right upper quadrant. Laboratory studies showed a white cell count of 21,000/µL and total bilirubin level of 9.1 mg/dL on admission. CT revealed acute calculous cholecystitis (Fig. A). Endoscopic retrograde biliary drainage was performed for suspicion of Mirizzi's syndrome and jaundice was significantly improved (Fig. B). Massive bloody stool with hypovolemic shock occurred 5 days later. No abnormalities were observed on esophagogastroduodenoscopy. Colonoscopy revealed a protruding mass with superficial ulceration in the hepatic fracture (Fig. C). What is the most likely diagnosis?

Answer to the Images: Cholecystocolic Fistula

The patient was taken to the operating room for exploration. A 3-mm fistulous tract was identified on the hepatic flexure of the colonic lumen (Fig. D). A segment of the transverse colon was resected, and cholecystectomy was performed. On pathological examination, the mucosa of the colon was focally necrotic. Meanwhile, a 2.5-cm fistula was connected to the gallbladder, and a calcium bilirubinate stone was found in the fistula (Fig. E, arrows; H&E, ×100). These findings were consistent with a diagnosis of cholecystocolic fistula.

Biliary-enteric fistulas have been found in 0.9% of patients undergoing biliary tract surgery.1 The most common site was the cholecystoduodenal fistula (70%), followed by cholecystocolic fistula (10%–20%).1 Diarrhea was the most common and valuable distinguishing symptom of cholecystocolic fistula.2 Other symptoms of abdominal pain, cholangitis, weight loss, and bowel obstruction were reported.2,3 Lower gastrointestinal bleeding was a rare presentation. The intermittent bleeding occurred from the stone necrosis of the gallbladder wall contiguous with the inflamed colon, and the migrating stone in the fistula could erode and seal off the bleeding vessels. Awareness of symptoms coupled with colonoscopic examination, barium enema, or biliary scintigraphy is required to make a preoperative diagnosis.

References
  1. Glenn, F, Reed, C, and Grafe, WR (1981). Biliary enteric fistula. Surg Gynecol Obstet. 153, 527-531.
    Pubmed
  2. Hession, PR, Rawlinson, J, Hall, JR, Keating, JP, and Guyer, PB (1996). The clinical and radiological features of cholecystocolic fistulae. Br J Radiol. 69, 804-809.
    Pubmed
  3. Correia, MF, Amonkar, DP, Nayak, SV, and Menezes, JL (2009). Cholecystocolic fistula: a diagnostic enigma. Saudi J Gastroenterol. 15, 42-44.
    Pubmed


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