Cholecystocutaneous Fistula Workup

  • Author: Cherry Ee Peck Koh, FRACS, MBBS, MS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Aug 5, 2011
 

Laboratory Studies

  • Hematology
    • Full blood examination (FBE): Leukocytosis supports an infective and inflammatory process.
    • C-reactive protein (CRP): An elevated CRP level indicates the presence of an infective process.
    • Liver function test (LFT) and alkaline phosphatase (ALP): levels are typically elevated because of extrahepatic duct obstruction (cystic duct). However, jaundice is uncommon, even in the presence of choledocholithiasis.[60]
  • Microbiology: Analysis of fluid discharged from the fistula reveals the type of fluid present (eg, bilirubin in bile) and provides bacteriologic results (purulent fluid guides antibiotic therapy). Common offending bacteria include Escherichia coli and Proteus species.
Next

Imaging Studies

The following imaging modalities can be used in the presence of a cholecystocutaneous fistula:

  • Ultrasonography
  • Computed tomography (CT) scanning
  • Fistulography
  • Cholangiography

Ultrasonography

A useful test, this can demonstrate gallstones, a thickened gallbladder adjacent to the anterior abdominal wall, and an overlying abdominal wall that is edematous due to inflammation. Occasionally, ultrasonography can demonstrate the gallbladder herniating into the subcutaneous tissue.[62] Inflammation of the skin occasionally limits examination because of pain.

Computed tomography scanning

CT scanning can demonstrate the unusual position of the gallbladder adhering to the anterior abdominal wall. CT scanning also demonstrates the presence of edema and, as seen in the image below, inflammation within the overlying tissue. In the event of a malignancy, a heterogeneous mass may be visible.

Computed tomography (CT) scan demonstrating a grosComputed tomography (CT) scan demonstrating a grossly inflamed gallbladder with a stone within the gallbladder, with partial gallbladder herniation into overlying abdominal wall musculature, marked overlying tissue inflammation, and fistulous tract.

Fistulography

This is useful in establishing the diagnosis. The contrast demonstrates the tract and fills the gallbladder. In an unobstructed system, fistulography also demonstrates the common bile duct, allowing examination of biliary anatomy. Rarely, in the event of multiple fistulae, it demonstrates communication with other, neighboring viscera.

Cholangiography

This demonstrates biliary anatomy and excludes the concomitant presence of a common bile duct stone, which should be addressed during resection of the fistula and gallbladder. If the patient is to be treated conservatively, this is particularly important, as an obstructed common bile duct can prevent spontaneous fistula closure.

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Contributor Information and Disclosures
Author

Cherry Ee Peck Koh, FRACS, MBBS, MS  Surgical Registrar, Department of General Surgery, Alfred Hospital, Bayside Health

Cherry Ee Peck Koh, FRACS, MBBS, MS is a member of the following medical societies: Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

David Merenstein, MBBS, FRACS  Consulting Staff, General and Endocrine Surgery, Department of Surgery, Monash Medical Centre, Faculty of Medicine, Nursing and Health Services; Consulting Staff, Sandringham and District Hospital, William Angliss Hospital and West Gippsland Hospital

David Merenstein, MBBS, FRACS is a member of the following medical societies: Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Simon Roger Berry, MBBS  General, UGI, and HPB Surgeon, Surgical Consulting Group, Cabrini Hospital, Australia

Simon Roger Berry, MBBS is a member of the following medical societies: Australian Medical Association, Australian Medical Association, International Hepato-Pancreato-Biliary Association, and Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David L Morris, MD, PhD, FRACS  Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

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A 90-year-old man referred with abdominal wall abscess in the right upper quadrant.
Computed tomography (CT) scan demonstrating a grossly inflamed gallbladder with a stone within the gallbladder, with partial gallbladder herniation into overlying abdominal wall musculature, marked overlying tissue inflammation, and fistulous tract.
Table. Case Reports of Cholecystocutaneous Fistula in the Past 50 Years From 1961 to 2011
Author(s)Year PublishedNumber of CasesCountry of Origin
Gordon et al[6] 20111United States of America
Sayed et al[7] 20101United Kingdom
Pezzilli et al[8] 20101Italy
Metsemakers et al[9] 20101Belgium
Tallon Aquilar et al[10] 20101Spain
Hawari et al[11] 20101United Kingdom
Gandhi et al[12] 20091New Zealand
Murphy et al[13] 20081United Kingdom
Ijaz et al[14] 20081United Kingdom
Chatterjee et al[15] 20071India
Malik et al[16] 20071United Kingdom
Nagral et al[17] 20071India
Marwah et al[18] 20071India
Shrestha et al[19] 20061United Kingdom
Cruz et al[20] 20061Brazil
Salvador-Izquierdo et al[21] 20061Spain
Yuceyar et al[22] 20051Turkey
Khan et al[23] 20051Saudi Arabia
Dutriaux et al[24] 20051France
Gossage et al[25] 20041United Kingdom
Vasanth et al[26] 20041United States of America
Mathonnet et al[27] 20021France
Chang et al[28] 20021Taiwan
Flora et al[29] 20011United Kingdom
Ramos Rincon et al[30] 20011Spain
Nicholson et al[31] 19991United States of America
Avital et al[32] 19981Israel
Kumar[33] 19981United States of America
Andley et al[34] 19961India
Birch et al[35] 19911United Kingdom
Carragher et al[36] 19901United Kingdom
Rosario et al[37] 19901United States of America
Sevonius et al[38] 19881Sweden
Gibson et al[39] 19871United Kingdom
Bilanovic et al[40] 19871Croatia
Tuna et al[41] 19861United States of America
Hakaim et al[42] 19861United States of America
Rye et al[43] 19851Denmark
Kulicki et al[44] 19841Poland
Davies et al[45] 19841United Kingdom
Abril et al[46] 19841United States of America
Nayman[47] 19831Australia
Ulreich et al[48] 19831United States of America
Hoffman et al[49] 19821United States of America
Fitchett et al[50] 19701United States of America
Callen[51] 19791United States of America
Orr[52] 19791Australia
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