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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
CHOLECYSTO-COLIC FISTULAF Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Description Fistulas between the gallbladder and the GI tract are most frequently a complication of acute cholecystitis. They do not present in a pathognomonic fashion and the diagnosis is often only established at surgical exploration. A high index of suspicion is required for establishing the diagnosis intraoperatively leading to proper and ideal management of the patients. This case illustrates the presentation and management of a cholecysto-colic fistula. 2. KeywordsAcute cholecystitis, cholecysto-colic fistula, complications of cholecystitis 3. PatientFemale, 89-year-old 4. Past medical history- history of previous stroke with minimal residual sequelae; - non-insulin dependent diabetes mellitus; - known hiatal hernia; - history of atrial fibrillation. 5. History of present illnessThe patient presents with a 72-hour history of diffuse abdominal pain radiating to the chest with nausea, frequent belching and progressive abdominal distension. She denies fever or vomiting. 6. Physical examination- BP 100/80; - P: 95/min; - T: 37,3° C; - tender abdomen with a large right upper quadrant mass that descends almost to the level of the pelvis; - no peritoneal signs. 7. Laboratory values- WBC: 21.4 10*3 / mm3 (92% neutrophils); - CRP: 200; - AST: 55 IU/l (N<29); - ALT: 24 IU/l (N<38); - amylase, lipase, bilirubin, gamma GT and alkaline phosphatase: normal. 8. Flat abdominal plateMassively distended GB reaching the pelvis with pneumatosis of the GB wall. 9. UltrasonographyHuge distended gallbladder (14x18 cm), reaching the bladder, with stones and sludge but no biliary ductal dilatation. 10. CT scanMassively distended gallbladder measuring 14x18 cm, reaching the pelvis, with stones (2 large ones) and sludge, but no biliary ductal dilatation. The presence of pneumatosis of the gallbladder wall as well as air within the gallbladder indicates either a severe infection with gas forming bacteria or a fistula with a nearby hollow organ. 11. Laparoscopic explorationAfter proper fluid and electrolyte resuscitation and administration of preoperative antibiotic therapy, a laparoscopic exploration is undertaken. The findings on CT scan are confirmed with purulent cholecystitis. Due to the fragile nature of the GB wall, it perforates and mandates conversion to an open procedure. At laparotomy, a gangrenous cholecystitis with a cholecysto-colic fistula is found. A cholecystectomy and right colectomy are performed. Postoperative recovery is uneventful. The brief video below illustrates the laparoscopy part of the procedure with the purulent cholecystitis and perforation of the GB wall before conversion. 12. DiscussionAcute calculous cholecystitis is caused by obstruction of the cystic duct by a stone. Fistulization occurs when the gallbladder becomes attached to a gastrointestinal hollow organ and perforates into it. The duodenum is the most common site of such fistulization, followed by the colon. Fistulization accounts for approximately 15% of the complications of acute cholecystitis. The development of a fistulous tract from the gallbladder is associated with gallstones in 90% of cases. Cholecysto-colic fistulas (CCF) account for 10% to 20% of all enteric-biliary fistulas. These complications are not consistently manifested by a specific symptom complex. The diagnosis is usually suggested by the presence of gas in the biliary tract. Complications of cholecysto-enteric fistulas include hyponatremia, due to the high sodium content of bile, weight loss due to malabsorption from the loss of bile acids, and infection. The treatment should be directed at treating urgent complications first (bowel obstruction, cholangitis) and dealing with the fistula itself either at the same time or in a delayed fashion depending on the general medical condition of the patient. 13. References
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