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Special Feature
May 18, 2009

Image of the Month—Diagnosis

Arch Surg. 2009;144(5):481-482. doi:10.1001/archsurg.2009.64-b

The cholecystocolonic fistula (CCF) represents 15% of all cholecystoenteric fistulas, thus being the second most frequent after the colecysto-duodenal fistula.1Unlike fistulas between the gallbladder and proximal gastrointestinal tract, often revealed by intestinal obstruction, more than 90%2of CCF cases are discovered during laparoscopic cholecystectomy. Such misdiagnosis may result in a challenging situation for the surgeon, who must achieve a diagnosis, usually while managing multiple adhesions, and must switch from a very low-morbidity surgery, sometimes during laparoscopy, to a procedure that is harder to perform and is usually in older patients with comorbidities.

In fact, symptoms of CCF are nonspecific, thus being neglected for years. Diarrhea1,3,4due to the malabsorption of biliary acids that bypass the terminal ileum and Bahuin valve, and right hypochondrium pain1,5are the most frequent symptoms of CCF, although their lack of specificity reduces their usefulness. Jaundice and hyperpyrexia are more helpful because they may prompt exploration of the liver and hepatic loggia, but they are rare.3,4Although rarer than in cases of more proximal fistulas, emergency complications such as obstruction,5,6massive bleeding,7or hepatic abscess8have also been described and may help preoperatively achieve a correct diagnosis.