Cholecystoduodenal Fistula Due to Gallstone Disease Masquerading as a Duodenal Ulcer Bleed: A Case Report

Objective: Unusual clinical course Background: A cholecystoenteric fistula (CEF) is a rare complication of gall stone disease. While a cholecystoduodenal fistula is the most commonly occurring bilioenteric fistulous communication, cholecystocolonic, cholecystogastric and choledochoduodenal fistulas have also been described. Case Report: A 73-year-old woman presented with a 1-week history of melena on a background of acid reflux and no abdominal pain. A gastroscopy revealed kissing D1 ulcers with excretion of pus. Following a CT scan of the abdomen, the patient was referred to the surgical team for the management of acute cholecystitis with a cholecystoduodenal fistula. She underwent an open cholecystectomy with fistula take-down and repair of the duodenum in the same admission. Following an uneventful postoperative recovery, she was discharged on an empirical course of H. pylori eradication therapy. Discussion: Recurrent episodes of acute cholecystitis or chronic cholecystitis can lead to adhesions between the gall bladder and adjacent viscus. Gall stone impaction then can cause pressure necrosis, leading to a fistulation between the gall bladder and the viscus. Rarely, this presents with massive upper-gastrointestinal bleeding. Imaging with ultrasound can reliably diagnose cholelithiasis, cholecystitis, and pneumobilia, but is unlikely to help in the definitive diagnosis of a bilioenteric fistula, which requires cross-sectional imaging. Conclusions: Massive upper-gastrointestinal bleeding is a rare mode of presentation of CEF. Hemodynamic resuscitation and management of upper-GI bleed takes precedence, followed by definitive management of the CEF after establishment of the diagnosis.