Laboratory Studies

Blood studies to be considered include the following:

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 tests (LFTs) 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 ^[67]

Microbiologic 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.

Imaging Studies

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

Ultrasonography (US)
Computed tomography (CT)
Fistulography
Cholangiography

US is useful for demonstrating gallstones, a thickened gallbladder adjacent to the anterior abdominal wall, and an overlying abdominal wall that is edematous as a consequence of inflammation. Occasionally, it can demonstrate the gallbladder herniating into the subcutaneous tissue.^[54]Inflammation of the skin occasionally limits examination because of pain.

CT can demonstrate the unusual position of the gallbladder adhering to the anterior abdominal wall. It also demonstrates the presence of edema, as well as inflammation within the overlying tissue (see the image below). In the event of a malignancy, a heterogeneous mass may be visible.

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.

View Media Gallery

Fistulography is useful in establishing the diagnosis.^[71]The contrast demonstrates the tract and fills the gallbladder. In an unobstructed system, fistulography also demonstrates the common bile duct (CBD), allowing examination of biliary anatomy. Rarely, in the event of multiple fistulae, it demonstrates communication with other, neighboring viscera.

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

Treatment & Management

Wang YF, Chen HQ. Hepatobiliary and Pancreatic: Spontaneous cholecystocutaneous fistula. J Gastroenterol Hepatol. 2019 Jan. 34 (1):11. [QxMD MEDLINE Link]. [Full Text].
Mathew G, Tuma F. Fistula, cholecystocutaneous. Treasure Island, FL: StatPearls; 2019. [Full Text].
Micu BV, Andercou OA, Micu CM, Militaru V, Jeican II, Bungărdean CI, et al. Spontaneous cholecystocutaneous fistula as a primary manifestation of gallbladder adenocarcinoma associated with gallbladder lithiasis - case report. Rom J Morphol Embryol. 2017. 58 (2):575-583. [QxMD MEDLINE Link].
Horhammer Cl. Ueberestraperitonealeperforatio der Gallenblase. Munchener Medizinische Wochenschrift. October 1916. 10:1451-1452.
Courvoisier L. Pathologie and Chirurgie der Gallenwege. FCW Vogel: Leipzig, Germany; 1890.
Naunyn B. Ulcerative affections of the biliary passage and fistula formation. A Treatise on Cholelithiasis. New Syndenham Society; (English version 1896). New Syndenham Society: 1892. 138-151.
Bonnet. Fistulebiliairecutanee. Lyon Med. 1897. 85:
Henry CL, Orr TG. Spontaneous external biliary fistulas. Surgery. 1949. 26(4):641-646.
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].
Vasanth A, Siddiqui A, O'Donnell K. Spontaneous cholecystocutaneous fistula. South Med J. 2004 Feb. 97(2):183-5. [QxMD MEDLINE Link].
Lau MW, Hall CN, Brown TH. Biliary-cutaneous fistula: an uncommon complication of retained gallstones following laparoscopic cholecystectomy. Surg Laparosc Endosc. 1996 Apr. 6(2):150-1. [QxMD MEDLINE Link].
Weiler H, Grandel A. Postoperative fistula of the abdominal wall after laparascopic cholecystectomy due to lost gallstones. Eur J Ultrasound. 2002 Jun. 15(1-2):61-3. [QxMD MEDLINE Link].
Shrestha BM, Wyman A. Cholecystocolocutaneous fistula: a case report. Hepatobiliary Pancreat Dis Int. 2006 Aug. 5(3):462-4. [QxMD MEDLINE Link].
Lofgren DH, Vasani S, Singzon V. Abdominal Wall Abscess Secondary to Cholecystocutaneous Fistula via Percutaneous Cholecystostomy Tract. Cureus. 2019 Apr 12. 11 (4):e4444. [QxMD MEDLINE Link]. [Full Text].
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].
Dadoukis J, Prousalidis J, Botsios D, et al. External biliary fistula. HPB Surg. 1998. 10(6):375-7. [QxMD MEDLINE Link]. [Full Text].
Sodhi K, Athar M, Kumar V, Sharma ID, Husain N. Spontaneous cholecysto-cutaneous fistula complicating carcinoma of the gall bladder: a case report. Indian J Surg. 2012 Apr. 74(2):191-3. [QxMD MEDLINE Link].
Ozdemir Y, Yucel E, Sucullu I, Filiz I, Gulec B, Akin ML. Spontaneous cholecystocutaneous fistula as a rare complication of gallstones. Bratisl Lek Listy. 2012. 113(7):445-7. [QxMD MEDLINE Link].
Andersen P, Friis-Andersen H. [Spontaneous cholecystocutaneous fistula presenting in the right breast]. Ugeskr Laeger. 2012 Apr 30. 174(18):1235-6. [QxMD MEDLINE Link].
Ioannidis O, Paraskevas G, Kotronis A, Chatzopoulos S, Konstantara A, Papadimitriou N. Spontaneous cholecystocutaneous fistula draining from an abdominal scar from previous surgical drainage. Ann Ital Chir. 2012 Jan-Feb. 83(1):67-9. [QxMD MEDLINE Link].
Batty L, Freeman L, Dubrava Z. A spontaneous cholecystocutaneous fistula. ANZ J Surg. 2011 Nov. 81(11):847. [QxMD MEDLINE Link].
Cheng HT, Wu CI, Hsu YC. Spontaneous cholecystocutaneous fistula managed with percutaneous transhepatic gallbladder drainage. Am Surg. 2011 Dec. 77(12):E285-6. [QxMD MEDLINE Link].
Khan A, Rajendran S, Baban C, Murphy M, O'Hanlon D. Spontaneous cholecystocutaneous fistula. BMJ Case Rep. 2011 Jul 20. 2011:[QxMD MEDLINE Link].
Gordon PE, Miller DL, Rattner DW, Conrad C. Image of the month. Cholecystocutaneous fistula (Jean-Louis Petit phlegmon). Arch Surg. 2011 Apr. 146(4):487-8. [QxMD MEDLINE Link].
Sayed L, Sangal S, Finch G. Spontaneous cholecystocutaneous fistula: a rare presentation of gallstones. J Surg Case Rep. 2010 Jul 1. 2010 (5):5. [QxMD MEDLINE Link]. [Full Text].
Pezzilli R, Barakat B, Corinaldesi R, Cavazza M. Spontaneous Cholecystocutaneous Fistula. Case Rep Gastroenterol. 2010 Sep 15. 4(3):356-360. [QxMD MEDLINE Link]. [Full Text].
Metsemakers WJ, Quanten I, Vanhoenacker F, Spiessens T. Spontaneous cholecystocutaneous abscess. JBR-BTR. 2010 Jul-Aug. 93(4):198-200. [QxMD MEDLINE Link].
Tallon Aguilar L, Lopez Porras M, Molina Garcia D, Bustos Jimenez M, Tamayo Lopez 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].
Yuceyar S, Erturk S, Karabicak I, Onur E, Aydogan 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, 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 Rincon JM, Fernandez Frias A, Costa Navarro D, 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].
Bilanovic D, Colovic R. [Spontaneous cholecystocutaneous fistula]. Acta Chir Iugosl. 1987. 34(1):65-8. [QxMD MEDLINE Link].
Tuna IC, Maizel S, O'Connor M, Humphrey EW. Simultaneous cholecystocutaneous and cholecystoduodenal fistulae. Minn Med. 1986 Feb. 69(2):77-8. [QxMD MEDLINE Link].
Hakaim AG, Vogt DP. Spontaneous cholecystocutaneous fistulas. Cleve Clin Q. 1986 Winter. 53(4):363-5. [QxMD MEDLINE Link].
Rye B, Jorgensen U. [Spontaneous cholecystocutaneous fistula]. Ugeskr Laeger. 1985 Jul 15. 147(29):2305-6. [QxMD MEDLINE Link].
Kulicki M. [Case of cholecystocutaneous fistula]. Wiad Lek. 1984 Jun 15. 37(12):955-7. [QxMD MEDLINE Link].
Davies CJ, Fontaine CJ. Spontaneous cholecysto-umbilical fistula. Br J Radiol. 1984 Nov. 57(683):1034-6. [QxMD MEDLINE Link].
Abril A, Ulfohn A. Spontaneous cholecystocutaneous fistula. South Med J. 1984 Sep. 77(9):1192-3. [QxMD MEDLINE Link].
Nayaman J. Empyema necessitatis of the gall-bladder. Med J Aust. 1963 Mar 23. 1:429-30. [QxMD MEDLINE Link].
Ulreich S, Henken EM, Levinson ED. Imaging in the diagnosis of cholecystocutaneous fistulae. J Can Assoc Radiol. 1983 Mar. 34(1):39-41. [QxMD MEDLINE Link].
Hoffman L, Beaton H, Wantz G. Spontaneous cholecystocutaneous fistula: a complication of neglected biliary tract disease. J Am Geriatr Soc. 1982 Oct. 30(10):632-4. [QxMD MEDLINE Link].
Fitchett CW. Spontaneous external biliary fistula. Va Med Mon (1918). 1970 Sep. 97(9):538-43. [QxMD MEDLINE Link].
Callen JP. Cholecystocutaneous fistula. Int J Dermatol. 1979 Jan-Feb. 18(1):63-4. [QxMD MEDLINE Link].
Orr KB. Spontaneous external biliary fistula. Aust N Z J Surg. 1979 Oct. 49(5):584-5. [QxMD MEDLINE Link].
Kassi ABF, Koffi E, Yénon KS, Bombet-Kouamé C. Cholecystoparietal Fistula Revealed by an Epigastric Abscess. Case Rep Gastroenterol. 2017 Jan-Apr. 11 (1):225-228. [QxMD MEDLINE Link]. [Full Text].
Davies MG, Tadros E, Gaine S, McEntee GP, Gorey TF, Hennessy TP. Combined internal and external biliary fistulae treated by percutaneous cholecystlithotomy. Br J Surg. 1989 Dec. 76(12):1258. [QxMD MEDLINE Link].
Gifford J, Saltzstein SL, Barone RM. Adenocarcinoma occurring in association with a chronic sinus tract and biliary fistula. Cancer. 1981 Apr 15. 47(8):2093-7. [QxMD MEDLINE Link].

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.

of 2

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^[17]		2012		1		India
Ozdemir et al^[18]		2012		1		Turkey
Andersen et al^[19]		2012		1		Denmark
Ioannidis et al^[20]		2012		1		Italian
Baty et al^[21]		2011		1		Australia
Cheng et al^[22]		2011		1		Taiwan
Khan et al^[23]		2011		1		Ireland
Gordon et al^[24]	2011		1		United States of America
Sayed et al^[25]	2010		1		United Kingdom
Pezzilli et al^[26]	2010		1		Italy
Metsemakers et al^[27]	2010		1		Belgium
Tallon Aquilar et al^[28]	2010		1		Spain
Hawari et al^[29]	2010		1		United Kingdom
Gandhi et al^[30]	2009		1		New Zealand
Murphy et al^[31]	2008		1		United Kingdom
Ijaz et al^[32]	2008		1		United Kingdom
Chatterjee et al^[33]	2007		1		India
Malik et al^[34]	2007		1		United Kingdom
Nagral et al^[35]	2007		1		India
Marwah et al^[36]	2007		1		India
Shrestha et al^[37]	2006		1		United Kingdom
Cruz et al^[38]	2006		1		Brazil
Salvador-Izquierdo et al^[39]	2006		1		Spain
Yuceyar et al^[40]	2005		1		Turkey
Khan et al^[41]	2005		1		Saudi Arabia
Dutriaux et al^[42]	2005		1		France
Gossage et al^[43]	2004		1		United Kingdom
Vasanth et al^[44]	2004		1		United States of America
Mathonnet et al^[45]	2002		1		France
Chang et al^[46]	2002		1		Taiwan
Flora et al^[47]	2001		1		United Kingdom
Ramos Rincon et al^[48]	2001		1		Spain
Nicholson et al^[49]	1999		1		United States of America
Avital et al^[50]	1998		1		Israel
Kumar^[51]	1998		1		United States of America
Andley et al^[52]	1996		1		India
Birch et al^[53]	1991		1		United Kingdom
Carragher et al^[54]	1990		1		United Kingdom
Rosario et al^[55]	1990		1		United States of America
Sevonius et al^[56]	1988		1		Sweden
Gibson et al^[57]	1987		1		United Kingdom
Bilanovic et al^[58]	1987		1		Croatia
Tuna et al^[59]	1986		1		United States of America
Hakaim et al^[60]	1986		1		United States of America
Rye et al^[61]	1985		1		Denmark
Kulicki et al^[62]	1984		1		Poland
Davies et al^[63]	1984		1		United Kingdom
Abril et al^[64]	1984		1		United States of America
Nayman^[65]	1983		1		Australia
Ulreich et al^[66]	1983		1		United States of America
Hoffman et al^[67]	1982		1		United States of America
Fitchett et al^[68]	1970		1		United States of America
Callen^[69]	1979		1		United States of America
Orr^[70]	1979		1		Australia

Back to List

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.

Cholecystocutaneous Fistula Workup

Laboratory Studies

Imaging Studies

References

Tables

Contributor Information and Disclosures

What would you like to print?