A 58-year-old man with a history of Crohn’s disease (A2L2B1 p), bile stones, migraine,
and chronic depression presented with an 11-kg weight loss and asthenia during the
preceding 6 months. He was receiving treatment with infliximab, azathioprine, mirtazapine,
and lorazepam. Laboratory tests showed a slightly elevated C-reactive protein (CRP)
of 35 mg/dL. He underwent a computed tomography (CT) scan that demonstrated gallbladder-wall
calcification, with no cleavage plane between the second portion of the duodenum and
the gallbladder ([Fig. 1]).
Fig. 1 Computed tomography (CT) image obtained after the administration of intravenous contrast
showing calcification of the gallbladder wall, the absence of a cleavage plane between
the second portion of the duodenum (D) and the gallbladder (G).
Upper gastrointestinal endoscopy showed that the duodenal bulb had a bulky appearance
with ulceration of the anterior duodenal wall ([Fig. 2]). Luminal contrast-enhanced endoscopic ultrasound (EUS) with instillation of a 50/50
polyethylene glycol and distilled water solution was used to create a hyperechogenic
lumen. Shortly after this, a hyperechoic fistula tract was observed connecting the
duodenal wall to the gallbladder wall ([Video 1]).
Fig. 2 View during upper gastrointestinal endoscopy showing a bulky appearance of the duodenal
bulb, with ulceration of the anterior duodenal wall.
Contrast-enhanced endoscopic ultrasound (EUS) demonstrating a hyperechoic fistula
tract between the duodenum and the gallbladder wall after instillation of luminal
contrast.
The patient underwent cholecystectomy with fistula section and closure of the duodenal
fistula orifice. Pathological examination revealed chronic inflammation of the duodenal
mucosa that was adherent to the gallbladder wall, including an acute necrohemorrhagic
inflammatory process with perforation and fibrosis related to intramural lithiasis.
The patient’s recovery after surgery was unremarkable and 2 months after the procedure
he had gained 4 kg.
Spontaneous enterobiliary fistula is a complication that is typically associated with
gallstones (90 %) [1]. It has also been reported with abdominal trauma, Crohn’s disease, peptic ulcer
disease, and malignancies of the biliary tract, bowel, and pancreas [2]
[3]. The symptoms associated with enterobiliary fistulas are nonspecific, with presenting
features often including abdominal pain, nausea, weight loss, and obstruction of the
small bowel or colon by the gallstone. Recurrent episodes of untreated cholecystitis
caused by stone obstruction of the cystic duct can produce adhesions between the gallbladder
and bowel, as in this case [4]. Most reported cases are identified intraoperatively during laparoscopic surgery.
In this case, preoperative diagnosis was possible using luminal contrast-enhanced
EUS.
Endoscopy_UCTN_Code_CCL_1AF_2AF
