Cholecystoduodenal fistula presenting as multiple hepatic lesions in a patient with pneumobilia

A 57 year-old man presented with upper respiratory symptoms, malaise, non-specific aches and pains, nausea, vomiting, and weight loss. On physical examination he had firm hepatosplenomegaly. The patient's past medical history was unremarkable for gastrointestinal disease. A contrast-enhanced computed tomography scan revealed multiple hepatic lesions and pneumobilia [Figure 1]. A few fine-needle aspirations were obtained from the liver lesions and an upper gastrointestinal series was performed. Following the liver biopsy the patient developed fever, leukocytosis and sepsis, and eventually underwent an exploratory laparotomy. The CT scan [Figure 1A] and upper gastrointestinal series [Figure 2] show pneumobilia (small black arrows), gas and contrast in the gallbladder (large black arrows) and a cholecystoduodenal fistula (open arrows) extending to the immediate post bulbar segment of the duodenum (white arrow). A more cephalad CT image [Figure 1B] shows multiple large non-enhancing hypo-attenuating liver lesions within the right hepatic lobe, proven by biopsy to be hepatic abscesses (large black arrows). These findings are consistent with a cholecystoduodenal fistula complicated by ascending cholangitis and multiple hepatic abscesses. Laparotomy demonstrated a cholecystoduodenal fistula, which was treated with division and closure and cholecystectomy. Pathologic examination of the resected gallbladder disclosed calculi and chronic fibrous cholecystitis. Biliary-enteric fistulas are a communication of the biliary tract to the bowel, most commonly to the duodenum and much less frequently to the colon, stomach, or other segments of the gastrointestinal tract. The reported incidence of spontaneous internal biliary fistulas is 0.4± 1.9% [1±4]. Cholecystoduodenal fistula is the most common type, occurring in 50± 76% of cases [2±4]. Less common types of biliary-enteric fistulas are cholecystocolic fistula (occurring in 13±21%) and choledochoduodenal fistulas (13±19%). Cholecystoduodenal fistula is often spontaneous, with approximately 90% of cases due to cholelithiasis, usually with chronic cholecystitis or choledocholithiasis. Other etiologies include peptic ulcer disease, neoplasms of the gastrointestinal tract, inflammatory bowel disease, trauma, or congenital malformation [1±4]. Since signs and symptoms are nonspecific, a high index of suspicion is needed to make the diagnosis. Imaging plays an important role in early diagnosis and prevention of possible complications, Figure 1. Contrast-enhanced CT scan of the abdomen A B