History

Most patients with cholecystocutaneous fistulae have a history suggestive of biliary disease; however, these symptoms are unlikely to be severe, in that an acute attack would have precipitated early presentation for surgical intervention. Depending on the stage of progression, patients may present with empyema necessitatis or a discharging sinus.^[62] Empyema necessitatis simply refers to a cholecystic abscess prior to rupture.

The patient may report systemic symptoms (eg, fevers, sweats, and anorexia associated with the infection) or a tender lump at the site of impending perforation. Patients in whom fistulae have discharged may report loss of bilious fluid or small stones via the external opening. The fistula itself is usually painless.

Physical Examination

The patient may be febrile and diaphoretic because of the infection. Prior to rupture, a raised, erythematous, tender, hot area of affected skin may be observed (see the image below). The surrounding skin is often cellulitic, frequently leading to an initial diagnosis of abscess. An associated lump under the skin may be observed if the gallbladder has herniated through the overlying tissue or if an associated malignancy is present.

A 90-year-old man referred with abdominal wall abscess in the right upper quadrant.

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The external opening is usually in the right upper quadrant,^[1]though external openings in the periumbilical area, the lumbar area, and even the gluteal area have been described. The discharge varies depending on whether an obstruction is present. Discharge may be purulent in the presence of empyema, mucoid in the presence of a mucocele because of obstruction, or bilious in the absence of obstruction. Small stones within the discharge often confirm the diagnosis.

Differential Diagnoses

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Metsemakers WJ, Quanten I, Vanhoenacker F, Spiessens T. Spontaneous cholecystocutaneous abscess. JBR-BTR. 2010 Jul-Aug. 93 (4):198-200. [QxMD MEDLINE Link].
Tallón Aguilar L, López Porras M, Molina García D, Bustos Jiménez M, Tamayo López MJ. [Cholecystocutaneous fistula: a rare complication of gallstones]. Gastroenterol Hepatol. 2010 Aug-Sep. 33 (7):553-4. [QxMD MEDLINE Link].
Hawari M, Wemyss-Holden S, Parry GW. Recurrent chest wall abscesses overlying a pneumonectomy scar: an unusual presentation of a cholecystocutaneous fistula. Interact Cardiovasc Thorac Surg. 2010 May. 10 (5):828-9. [QxMD MEDLINE Link].
Gandhi J, Gandhi N. Abdominal wall abscess: more than meets the eye. BMJ Case Rep. 2010. 2010:[QxMD MEDLINE Link]. [Full Text].
Murphy JA, Vimalachandran CD, Howes N, Ghaneh P. Anterior abdominal wall abscess secondary to subcutaneous gallstones. Case Rep Gastroenterol. 2008 Jul 9. 2 (2):219-23. [QxMD MEDLINE Link]. [Full Text].
Ijaz S, Lidder S, Mohamid W, Thompson HH. Cholecystocutaneous fistula secondary to chronic calculous cholecystitis. Case Rep Gastroenterol. 2008 Mar 11. 2 (1):71-5. [QxMD MEDLINE Link]. [Full Text].
Chatterjee S, Choudhuri T, Ghosh G, Ganguly A. Spontaneous cholecystocutaneous fistula in a case of chronic colculous cholecystitis--a case report. J Indian Med Assoc. 2007 Nov. 105 (11):644, 646, 656. [QxMD MEDLINE Link].
Malik AH, Nadeem M, Ockrim J. Complete laparoscopic management of cholecystocutaneous fistula. Ulster Med J. 2007 Sep. 76 (3):166-7. [QxMD MEDLINE Link]. [Full Text].
Nagral SS, Rao RG. Spontaneous cholecystocutaneous fistula. Bombay Hosp J. 2007 Oct. 49 (4):[Full Text].
Marwah S, Godara R, Sandhu D, Karwasra R. Spontaneous gallbladder perforation presenting as abdominal wall abscess. Internet J Surg. 2006. 12 (2):1-3. [Full Text].
Shrestha BM, Wyman A. Cholecystocolocutaneous fistula: a case report. Hepatobiliary Pancreat Dis Int. 2006 Aug. 5 (3):462-4. [QxMD MEDLINE Link].
Cruz RJ Jr, Nahas J, de Figueiredo LF. Spontaneous cholecystocutaneous fistula: a rare complication of gallbladder disease. Sao Paulo Med J. 2006 Jul 6. 124 (4):234-6. [QxMD MEDLINE Link].
Salvador-Izquierdo R, Gimeno-Solsona F. [Spontaneous cholecystocutaneous fistula in the ederly]. Med Clin (Barc). 2006 Sep 9. 127 (9):359. [QxMD MEDLINE Link].
Yüceyar S, Ertürk S, Karabiçak I, Onur E, Aydoğan F. Spontaneous cholecystocutaneous fistula presenting with an abscess containing multiple gallstones: a case report. Mt Sinai J Med. 2005 Nov. 72 (6):402-4. [QxMD MEDLINE Link].
Khan AA, Azhar MZ, Khan AA, Rasheed A, Khan KN. Spontaneous cholecystocutaneous fistula. J Coll Physicians Surg Pak. 2005 Nov. 15 (11):726-7. [QxMD MEDLINE Link].
Dutriaux C, Maillard H, Prophette B, Catala M, Célerier P. [Spontaneous cholecystocutaneous fistula]. Ann Dermatol Venereol. 2005 May. 132 (5):467-9. [QxMD MEDLINE Link].
Gossage J, Forshaw M, Stephenson J, Mason R. Spontaneous cholecysto-cutaneous fistula. J Surg. 2004. 2 (1):52-3. [Full Text].
Vasanth A, Siddiqui A, O'Donnell K. Spontaneous cholecystocutaneous fistula. South Med J. 2004 Feb. 97 (2):183-5. [QxMD MEDLINE Link].
Mathonnet M, Maisonnette F, Gainant A, Cubertafond P. [Spontaneous cholecystocutaneous fistula: natural history of biliary cholecystitis]. Ann Chir. 2002 May. 127 (5):378-80. [QxMD MEDLINE Link].
Chang SS, Lu CL, Pan CC, Chiou YY, Wang SS, Chang FY, et al. Spontaneous cholecystocutaneous fistula presenting with a cellulitis and portal vein thrombosis. J Clin Gastroenterol. 2002 Jan. 34 (1):99-100. [QxMD MEDLINE Link].
Flora HS, Bhattacharya S. Spontaneous cholecystocutaneous fistula. HPB (Oxford). 2001. 3 (4):279-80. [QxMD MEDLINE Link]. [Full Text].
Ramos Rincón JM, Fernández Frías A, Costa Navarro D, Agulló Royo MJ, Arroyo Sebastián A, Martín Hidalgo A, et al. [Spontaneous bilio-cutaneous fistula. A rare clinical entity]. Gastroenterol Hepatol. 2001 Oct. 24 (8):411-2. [QxMD MEDLINE Link].
Nicholson T, Born MW, Garber E. Spontaneous cholecystocutaneous fistula presenting in the gluteal region. J Clin Gastroenterol. 1999 Apr. 28 (3):276-7. [QxMD MEDLINE Link].
Avital S, Greenberg R, Goldwirth M, Werbin N, Skornik Y. A spontaneous discharging wound on the abdominal wall. Postgrad Med J. 1998 Aug. 74 (874):505-6. [QxMD MEDLINE Link]. [Full Text].
Kumar SS. Laparoscopic management of a cholecystocutaneous abscess. Am Surg. 1998 Dec. 64 (12):1192-4. [QxMD MEDLINE Link].
Andley M, Biswas RS, Ashok S, Somshekar G, Gulati SM. Spontaneous cholecystocutaneous fistula secondary to calculous cholecystitis. Am J Gastroenterol. 1996 Aug. 91 (8):1656-7. [QxMD MEDLINE Link].
Birch BR, Cox SJ. Spontaneous external biliary fistula uncomplicated by gallstones. Postgrad Med J. 1991 Apr. 67 (786):391-2. [QxMD MEDLINE Link]. [Full Text].
Carragher AM, Jackson PR, Panesar KJ. Subcutaneous herniation of gall-bladder with spontaneous cholecystocutaneous fistula. Clin Radiol. 1990 Oct. 42 (4):283-4. [QxMD MEDLINE Link].
Rosario PG, Gerst PH, Prakash K, Katter H. Cholecystocutaneous fistula: an unusual presentation. Am J Gastroenterol. 1990 Feb. 85 (2):214-5. [QxMD MEDLINE Link].
Sevonius D, Jóhannesson E. [Gluteal abscess shown to be a cholecystocutaneous fistula]. Lakartidningen. 1988 Mar 23. 85 (12):1061. [QxMD MEDLINE Link].
Gibson TC, Howat JM. Cholecystocutaneous fistula. Br J Clin Pract. 1987 Oct. 41 (10):980-2. [QxMD MEDLINE Link].
Bilanović D, Colović R. [Spontaneous cholecystocutaneous fistula]. Acta Chir Iugosl. 1987. 34 (1):65-8. [QxMD MEDLINE Link].
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Media Gallery

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.

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Table 1. Case Reports of Cholecystocutaneous Fistula From 1961 to 2013

Table 1. Case Reports of Cholecystocutaneous Fistula From 1961 to 2013

Author(s)	Year Published		Number of Cases		Country of Origin
Sodhi et al^[14]		2012		1		India
Ozdemir et al^[15]		2012		1		Turkey
Andersen et al^[16]		2012		1		Denmark
Ioannidis et al^[17]		2012		1		Italian
Baty et al^[18]		2011		1		Australia
Cheng et al^[19]		2011		1		Taiwan
Khan et al^[20]		2011		1		Ireland
Gordon et al^[21]	2011		1		United States of America
Sayed et al^[22]	2010		1		United Kingdom
Pezzilli et al^[23]	2010		1		Italy
Metsemakers et al^[24]	2010		1		Belgium
Tallon Aquilar et al^[25]	2010		1		Spain
Hawari et al^[26]	2010		1		United Kingdom
Gandhi et al^[27]	2009		1		New Zealand
Murphy et al^[28]	2008		1		United Kingdom
Ijaz et al^[29]	2008		1		United Kingdom
Chatterjee et al^[30]	2007		1		India
Malik et al^[31]	2007		1		United Kingdom
Nagral et al^[32]	2007		1		India
Marwah et al^[33]	2007		1		India
Shrestha et al^[34]	2006		1		United Kingdom
Cruz et al^[35]	2006		1		Brazil
Salvador-Izquierdo et al^[36]	2006		1		Spain
Yuceyar et al^[37]	2005		1		Turkey
Khan et al^[38]	2005		1		Saudi Arabia
Dutriaux et al^[39]	2005		1		France
Gossage et al^[40]	2004		1		United Kingdom
Vasanth et al^[41]	2004		1		United States of America
Mathonnet et al^[42]	2002		1		France
Chang et al^[43]	2002		1		Taiwan
Flora et al^[44]	2001		1		United Kingdom
Ramos Rincon et al^[45]	2001		1		Spain
Nicholson et al^[46]	1999		1		United States of America
Avital et al^[47]	1998		1		Israel
Kumar^[48]	1998		1		United States of America
Andley et al^[49]	1996		1		India
Birch et al^[50]	1991		1		United Kingdom
Carragher et al^[51]	1990		1		United Kingdom
Rosario et al^[52]	1990		1		United States of America
Sevonius et al^[53]	1988		1		Sweden
Gibson et al^[54]	1987		1		United Kingdom
Bilanovic et al^[55]	1987		1		Croatia
Tuna et al^[56]	1986		1		United States of America
Hakaim et al^[57]	1986		1		United States of America
Rye et al^[58]	1985		1		Denmark
Kulicki et al^[59]	1984		1		Poland
Davies et al^[60]	1984		1		United Kingdom
Abril et al^[61]	1984		1		United States of America
Nayman^[62]	1983		1		Australia
Ulreich et al^[63]	1983		1		United States of America
Hoffman et al^[64]	1982		1		United States of America
Fitchett et al^[65]	1970		1		United States of America
Callen^[66]	1979		1		United States of America
Orr^[67]	1979		1		Australia

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Author

Cherry Ee Peck Koh, MBBS, MS, FRACS Colorectal and General Surgeon, Royal Prince Alfred Hospital, Australia

Cherry Ee Peck Koh, MBBS, MS, FRACS 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: International Hepato-Pancreato-Biliary Association, Australian Medical Association, Australian Medical Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF 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, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.