Choledochoduodenal fistulas

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


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


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


We proceeded for UGI endoscopy

video attached


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


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



Incidence:

• Male : female ratio is 3:1

• 5th- 6th decade

• It has 2 types:

Proximal CDFs “ posterior bulb wall”

Distal CDFs “periampullary”


Aetiology of the spontaneous CDFs:

• Penetrating duodenal ulcer 80 % (PCDFs)

• Choledocholithiasis (DCDFs)

• Malignancies



Presentation :

• Asymptomatic “most common”

• Ascending cholangitis

• Obstructive jaundice

• UGIB “rare”



Diagnosis :

• Imaging

X-RAY

Pneumobilia



Diagnosis :

• Imaging

U/S

Pneumobilia



Diagnosis :

• Imaging

C.T.

Pneumobilia



Diagnosis :

• Endoscopy

UGI

ERCP




choledochoduodenal fistula and Cholangiogram was demonstrated by introducing contrast medium into the fistula


Management :

• Debate of MEDICAL versus SURGICAL

• Medical:

Asymptomatic or high risk



Management :

• Surgical:

• Used to be the main line “prophylactic”

• Reserved for failed medical, bleeding & biliary obstruction

Laparoscopic surgery

Vagotomy and gasterojejonostomy



Management :

• Other modalities

Endoscopic closure

over -the scope -clips







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


Thank you


Choledochoduodenal fistulas

Health & Medicine