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Op e n  Ac c e ss  
C a s e  R e p o r t  

 Chronic Gallstone Disease Presenting as Cholecystoduodenal 
Fistula 

Sajid Ali 1, Mohammad Zarin 2 

 1 Post graduate Resident, Department of Surgery, Khyber Teaching Hospital Peshawar 
2 Associate Professor Department of Surgery Khyber Teaching Hospital Peshawar 

 (Khyber Teaching Hospital Peshawar)

A B S T R A C T  

Cholecystoduodenal fistula (CDF) is the most common cholecystoenteric fistula. It is a late complication of gallbladder 

disease with calculus and is mainly encountered in the elderly and females. We report the case of a 60 years’ female 

patient with cholecystoduodenal fistula and gallstones. She had recurrent attacks of abdominal pain with anorexia and 

vomiting. Ultrasound abdomen demonstrated air in the biliary system. Computed tomography abdomen revealed 

pnemobilia and CDF tract. We did cholecystectomy and repair of CDH tract through Modified Graham’s repair. This case 

report suggests the importance of knowing the biliary anatomy through pre-op Magnetic resonance cholongio 

pancreatography (MRCP) or MRI abdomen and planning definitive procedure for bilioenteric fistulas. The patient’s 

clinical features and operative management are presented and discussed with current literature. 

Key Words: Bilioenteric fistula, Cholecystoduodenal fistula, Chronic Cholecystitis. 

Address of Correspondence 
Sajid Ali 
Email: dralisajid89@gmail.com 

 Article info. 
Received: August 24, 2017 
Accepted: September 12, 2017 

Cite this case Report: Ali S, Zarin M. Chronic Gallstone Disease Presenting as Cholecystoduodenal 
Fistula.. JIMDC;6(3):187-189. 

 

Funding Source: Nil 
Conflict of Interest: Nil 

I n t r o d u c t i o n  
 

Cholelithiasis is a common health condition and only few 

patients (around 1–3%) develop rare complications such 

as choledochoduodenal fistulas.1 Chronic cholecystitis 

with gallstones is the primary etiology in as many as 75% 

of CDF patients.3 The formation of biliroenteric fistula is 

initiated when the walls of the gallbladder and adjacent 

bowel are chronically inflamed and adherent. Increasing 

intraluminal pressure caused by obstruction leads to local 

ischemia and necrosis and ultimately communication.2 

Cholecystoduodenal fistula is a difficult problem usually 

diagnosed intra-operatively and is the most common 

indication of conversion from laparoscopic to open 

surgery. A high degree of suspicion is mandatory in 

difficult cases during surgery to prevent complications. 

The treatment for CDF is cholecystectomy and closure of 

fistulous communication. The laparoscopic stapling 

technique has been reported as feasible and safe 

methods to treat such fistula. Endostapler device is easy 

to use and is effective. The fistulous tract should be 

dissected clearly to demonstrate all-around anatomy and 

create adequate space to apply the endostapler.3 

C a s e  R e p o r t s  

A 60 years old non-diabetic non-hypertensive patient 

presented to our ward with 40 days’ history of pain in 

abdomen associated with anorexia and vomiting. She 

also gave a history of chronic constipation for which she 

was using on/off sodium picosulfate. There was no history 

of fever, jaundice or weight loss. On examination, she 

was found to have tender right hypochondrium and 

epigastric region and distended abdomen. Vitals were BP: 

130/80 mmHg, pulse 90/min, RR 18/min, and 

temperature: 990F. Ultrasound Abdomen and pelvis 

showed thickened irregular gallbladder with a gallstone 

which was 7.8mm. Total leukocyte count was 11300/ 

cmm, Hb 8.7gm/dl, platelets count 432000cmm, serum 

C A S E  R E P O R T  



 

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amylase 50u/l, total bilirubin 0.47mg/dl, serum alkaline 

phosphatase 285u/l (up to 275), ALT 42u/l, urea 

63.5mg/dl, creatinine 1.43mg/dl, albumin 1.61mg/dl (3.5-

6.5),s globulin 3.08 (1.8-3.6), serum calcium 8.7mg/dl. 

ESR was 120mm 1st hour. She was started on 

conservative management with IV fluids, IV cefuroxime  

Figure 1: Abdominal CT scan showing pnemobilia 

and fistulous communication between gallbladder and 

duodenum 

 

1.5gm B.D, painkillers and PPIs, but patient did not 

improve clinically and CT abdomen and pelvis was done 

which showed pnemobilia and fistulous communication.  

One day before surgery her investigations were: HB 

11.5gm/dl after two units of blood transfusions. TLC 

15500cmm, platlets count 361000cmm, S bilirubin 

0.91mg/dl, SALPO4 265u/l (upto 275), ALT 20u/l (10-40), 

urea 19mg/dl, creatinine 0.96mg/dl, PT control: 13sec, 

patient: 15sec, APTT control 28sec, patient 

28sec.Exploratory laparotomy was done through an upper 

midline incision and the following findings were noted 

• Perforated gallbladder 

• Cholecystoduodenal fistula 

• And gross ascites 

Procedure done was 

• Gallbladder resected 

• Duodenal defect closed with omentum (modified 

grahams repair) 

• Thorough wash and suction done 

• Two drains placed one in right side of subhepatic 

space and second in left side in pelvis 

The patient was shifted to surgical intensive care unit for 

post-operative care. Where she spent 2 weeks before 

fully stabilized and then was shifted to parent surgical E 

ward where she spent another week and was discharged 

successfully. The patient had no complications during 

6months of follow-up. 

 D i s c u s s i o n  

Cholelithiasis is a common problem and 

Cholecystoduodenal fistula is a rare complication of 

chronic gallstone disease.1,3 Cholecystoduodenal type 

accounts for as many as 80% of cholecystoenteric 

fistulas.4 Cholecystoduodenal fistula is generally 

considered a relative contraindication to laparoscopic 

cholecystectomy because of difficulties in its management 

intra-operatively. They are of two types non-obstructive 

and obstructive type, the former can present with 

cholangitis, weight loss and malabsorption syndrome 

while the latter with gallstone ileus or Bouveret syndrome, 

hematemesis or melena. MRI abdomen and MRCP 

should be ordered pre-operatively to delineate anatomy of 

biliary channels. Diagnosis can be a challenge and pre-
operative ultrasound, as well as CT scan of abdomen, 

may reveal pneumobilia.5-7 A cholecystoduodenal fistula is 

generally considered to be a relative contraindication to 

laparoscopic cholecystectomy because of difficult 

anatomy and risk of injuries to the duodenum and 

surrounding structures intra-operatively but studies have 

shown that laparoscopic technique can be implied if 

expertise are available with same principles of the careful 

release of adhesions cholecystectomy and closure of 

fistulous track with endostapling device.8,9 Careful 
preoperative workups for such patients should be done in 

order to plan definite treatment i.e. cholecystectomy and 

closure of fistulous tract.3,4  

C o n c l u s i o n  

A cholecystoduodenal fistula is a rare complication of 

chronic gallstone disease and therefore there should be a 



 

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high index of suspicion of biliary enteric fistula in chronic 

gallstone disease when patients present with the bizarre 

clinical picture. 

R e f e r e n c e s  

1. Thomson WL, Miranda S, Reddy A. An unusual presentation of 
cholecystoduodenal fistula: vomiting of gallstones. BMJ case 
reports. 2012; bcr2012007009. 

2. Nickel F, Müller-Eschner MM, Chu J, von Tengg-Kobligk H, 
Müller-Stich BP. Bouveret’s syndrome: presentation of two cases 
with review of the literature and development of a surgical 
treatment strategy. BMC surgery. 2013; 13(1) 
:33.  

3. Col ND. Successful laparoscopic management of four cases of 
cholecystoduodenal fistula. Medical Journal Armed Forces India. 
2012; 68(1):88-9. 

4. Constant E, Turcotte JG. Choledochoduodenal fistula: the natural 
history and management of an unusual complication of peptic 
ulcer disease. Annals of surgery. 1968; 167(2):220. 

5. Hill BC, Burke LH, Ertl CW. Cholecystoduodenal fistula in a 
patient post-Roux-en-Y gastric bypass. BMJ case reports. 2013; 
bcr2013200562. 

6. Arfin SQ, Haqqi SA, Shaikh H, Wakani AJ. Bouveret's syndrome: 
successful endoscopic treatment of gastric outlet obstruction 
caused by an impacted gallstone. Journal of the College of 
Physicians and Surgeons Pakistan. 2012; 22(3):174-5. 

7. Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E. 
Diagnosis and treatment of gallbladder perforation. World journal 
of gastroenterology: WJG. 2006; 12(48):7832. 

8. Faridi MS, Pandey A. Mirizzi syndrome type II with 
cholecystoduodenal fistula: an infrequent combination. The 
Malaysian journal of medical sciences: MJMS. 2014; 21(1): 69. 

9. Cahow Jr CE, Glenn F. Sequelae attributed to delayed surgical 
treatment of gallstones. Annals of surgery. 1965; 161(1):21.