Choledochoduodenal fistula Prof. Sherif Mogawer Shaimaa Elkholy Cairo University, Egypt Shaimaa Elkholy, M.D. Cairo University
Choledochoduodenal fistula
Prof. Sherif MogawerShaimaa Elkholy
Cairo University, Egypt
Shaimaa Elkholy, M.D. Cairo University
Case presentation
• A 55 years old male patient presenting withacute onset of epigasrtic pain associated withvomiting ,rigors, chills and fever reaching upto 39 c
• The patient had history of melena 5 years agofor which he was admitted to the hospital UGIendoscopy was done to him showing pepticulcer disease
Shaimaa Elkholy, M.D. Cairo University
Case presentation
• The patient was discharged on PPI that was
prescribed to him and he was instructed to
quit smoking and stop NSAIDs but the patient
was not compliant
• On examination the patient had epigastric
and right hypochondrial tenderness
Case presentation
Shaimaa Elkholy, M.D. Cairo University
Case presentation
• Laboratory tests showed: leucocytosis (13,500) with shift to the left
• Abdominal ultrasound showed microlithiasisof the gallbladder and presence of air in the common bile duct (pneumobilia)
Case presentation
Shaimaa Elkholy, M.D. Cairo University
Choledochoduodenal fistula (CDF)
Incidence:
• It’s a very rare condition
• Accounts for about 5 % of all bilio-enteric fistulas
• Bilio-enteric fistulas:
Cholecystoduodenal most common
Cholecyscolonic
Cholecystogastric
Shaimaa Elkholy, M.D. Cairo University
Choledochoduodenal fistula (CFD)
Its rarity referred to the fact that the commonest site of duodenal ulcer is about 4 cm from the pyloric ring and CBD is about 7 cm from the pylorus
Shaimaa Elkholy, M.D. Cairo University
Choledochoduodenal fistula (CDF)
Incidence:
• Male : female ratio is 3:1
• 5th- 6th decade
• It has 2 types:
Proximal CDFs “ posterior bulb wall”
Distal CDFs “periampullary”
Shaimaa Elkholy, M.D. Cairo University
Aetiology of the spontaneous CDFs:
• Penetrating duodenal ulcer 80 % (PCDFs)
• Choledocholithiasis (DCDFs)
• Malignancies
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Presentation :
• Asymptomatic “most common”
• Ascending cholangitis
• Obstructive jaundice
• UGIB “rare”
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Imaging
X-RAY
Pneumobilia
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Imaging
U/S
Pneumobilia
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Imaging
C.T.
Pneumobilia
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Endoscopy
UGI
ERCP
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
choledochoduodenal fistula and Cholangiogram was demonstrated by introducing contrast medium into the fistula
Shaimaa Elkholy, M.D. Cairo University
Management :
• Debate of MEDICAL versus SURGICAL
• Medical:
Asymptomatic or high risk
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Management :
• Surgical:
• Used to be the main line “prophylactic”
• Reserved for failed medical, bleeding & biliary obstruction
Laparoscopic surgery
Vagotomy and gasterojejonostomy
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Management :
• Other modalities
Endoscopic closure
over -the scope -clips
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Take home message
• CDFs rare sequel for long standing duodenal ulcer
• CDFs should be bared in mind when the patient starts to develop unusual symptoms e.g. jaundice , cholangitis
• Adequate biliary drainage should be ensured before management
• Endoscopic closure using over the scope clip may be the modality of choice
Shaimaa Elkholy, M.D. Cairo University