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

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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^[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

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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.

Cholecystocutaneous Fistula Workup

Laboratory Studies

Imaging Studies

References

Tables

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