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Special Feature
April 2011April 18, 2011

Image of the Month—Diagnosis

Arch Surg. 2011;146(4):488. doi:10.1001/archsurg.2011.66-b
Answer: Cholecystocutaneous Fistula (Jean-Louis Petit Phlegmon)

Spontaneous cholecystocutaneous fistulas have been reported since Thilesus in 1670.1 In 1890, 169 cases of spontaneous biliary fistula were reported by Courvosier,2 36 cases were reported by Henry and Ort in 1949,2 and only 16 cases were reported over the last 50 years.3 Presently, incidence is greatest in women older than 60 years or men younger than 24 years.1 Cholecystocutaneous fistulas occur as a result of the persistent inflammation of a perforated gallbladder, trauma, iatrogenic causes,4 neglected chronic cholecystitis,4 calculus cholelithiasis, or, infrequently, carcinomas.3 Fistulas develop primarily at the fundus of the gallbladder and can communicate with the abdominal parieties, duodenum, colon, stomach, gluteal region,4,5 chest wall, or thigh.1

Cholecystocutaneous fistulas typically present with a right upper quadrant, painless, fluctuant mass1; dyspepsia; abdominal wall cellulitis or suppuration; upper abdominal colic; or weight loss. Interestingly, cholecystocutaneous fistulas frequently are not preceded by an episode of acute cholecystitis.1,4 Diagnosis is best confirmed with ultrasonography, computed tomography, or fistulogram. Treatment options include source control through percutaneous management only (including stone removal) in high-risk patients, minimally invasive cholecystectomy, and open management with cholecystectomy. Percutaneous drainage, with potential spontaneous closure of the fistulous tract, is no longer the preferred approach because it requires the subsequent surgical procedure of cholecystectomy to prevent recurrence.3,4 Open surgical management is currently being considered the standard approach with cholecystectomy and external abscess drainage.3 However, with improving skills and expanding techniques in laparoscopic surgery, a minimally invasive approach may soon become the standard. It has been reported that laparoscopic management of cholecystocutaneous fistulas is safe and cost-effective.6 However, it is understood that basic principles in the laparoscopic management of gallbladder disease for cholecystocutaneous fistulas apply, which include obtaining the “critical view” with certainty and being mentally open to early conversion.

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Article Information

Correspondence: Claudius Conrad, MD, PhD, Harvard Medical School, Massachusetts General Hospital, Department of Surgery, 55 Fruit St, GRB-425, Boston, MA 02114 (cconrad1@partners.org).

Accepted for Publication: January 5, 2010.

Author Contributions:Study concept and design: Rattner and Conrad. Acquisition of data: Gordon and Conrad. Analysis and interpretation of data: Miller and Conrad. Drafting of the manuscript: Gordon, Miller, and Conrad. Critical revision of the manuscript for important intellectual content: Miller, Rattner, and Conrad. Administrative, technical, and material support: Miller, Rattner, and Conrad. Study supervision: Rattner and Conrad.

Financial Disclosure: None reported.

Submissions

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

References
1.
Birkett  DHBirkett  DHBirkett  DH Spontaneous cholecystocutaneous fistula. South Med J 2004;97 (2) 183- 185
PubMedArticle
2.
Birkett  DHOrt  TG  Jr Spontaneous external biliary fistulas. Surgery 1949;26 (4) 641- 646
PubMed
3.
Birkett  DHBirkett  DHBirkett  DHBirkett  DH Spontaneous combined internal and external biliary fistulae in association with gallstones and gliomatosis of the gallbladder. Revista Brasileira de Cancerologia 2001;47 (3) 273- 276
4.
Cruz  RJ  JrBirkett  DHBirkett  DH Spontaneous cholecystocutaneous fistula: a rare complication of gallbladder disease. Sao Paulo Med J 2006;124 (4) 234- 236
PubMedArticle
5.
Birkett  DHBirkett  DHBirkett  DH Spontaneous cholecystocutaneous fistula presenting in the gluteal region. J Clin Gastroenterol 1999;28 (3) 276- 277
PubMedArticle
6.
Birkett  DHBirkett  DHBirkett  DH Complete laparoscopic management of cholecystocutaneous fistula. Ulster Med J 2007;76 (3) 166- 167
PubMed
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