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May 18, 2009

Image of the Month—Diagnosis

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

Answer: Cholecystocolonic Fistula Associated With Escherichia coli Liver Abscess

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.

Of the proposed diagnostic means, barium enema4and endoscopic retrograde cholangiopancreatography (ERCP)3,4present a significant number of false negatives (barium enema,3,6ERCP1,4), are relatively invasive (ERCP, colonoscopy), or may not be considered routine (ERCP, scintigraphy) for patients with nonspecific symptoms. The CT scan may help diagnose CCF5,7in the case of precipitating complications such as bleeding,7biliary ileus,5or hepatic abscess. In this case, the 2-dimensional image allowed us to identify the hepatic abscess and pneumobilia in the gallbladder (Figure 1), whereas the 3-dimensional CT reconstruction showed the fistula to be between the gallbladder and colon (Figure 2), allowing us to plan the most appropriate procedure.

Figure 1 
. Computed tomographic scan (2-dimensional) of the abdomen shows a 5-cm abscess of fourth hepatic segment associated with pneumobilia.

. Computed tomographic scan (2-dimensional) of the abdomen shows a 5-cm abscess of fourth hepatic segment associated with pneumobilia.

Figure 2 
. Computed tomographic reconstruction (3-dimensional) of the abdomen shows a fistula between the gallbladder and the right transverse colon.

. Computed tomographic reconstruction (3-dimensional) of the abdomen shows a fistula between the gallbladder and the right transverse colon.

Many treatments of CCF exist, depending on the clinical picture. If the patient does not have gallstone ileus and the symptoms are strictly linked to CCF or if CCF is accidentally discovered at surgery, cholecystectomy and tangential transverse colon resection is proposed as a 1-stage procedure that may be accomplished by laparoscopy.1,3If a concomitant hepatic abscess is present, it should be surgically drained.8Conversely, if CCF is revealed by biliary ileus, it may be treated with operative colonoscopy9or enterolithotomy.5,6Depending on the conditions of the colon, a temporary colostomy may also be indicated.5Whether in older debilitated patients CCF should be treated at the same time10as a delayed procedure5or not at all6is still widely debated.

Our patient underwent a right subcostal incision and a difficult adhesiolysis. During the dissection, a sclerotic gallbladder, firmly adherent to the right transverse colon, was opened and a 1.5-cm faceted gallstone was extracted. Cholecystectomy was performed and the colon was tangentially resected by linear stapler; an intraoperative transcystic cholangiography showed no abnormalities. The hepatic collection was drained and a wide fenestration performed. Postoperative course was uneventful, and the patient was discharged on postoperative day 8.

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Correspondence:Renato Costi, MD, PhD, Dipartimento di Scienze Chirurgiche, Iniversità degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italia (

Accepted for Publication:October 23, 2008.

Author Contributions:Study concept and design: Costi, Bataille, and Cazaban. Analysis and interpretation of data: Costi and Montariol. Drafting of the manuscript: Costi, Bataille, and Cazaban. Critical revision of the manuscript for important intellectual content: Montariol. Administrative, technical, and material support: Cazaban. Study supervision: Costi and Montariol.

Financial Disclosure:None reported.

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