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Case Report
Cholecystocolonic Fistulas from Diverticulosis:
A Potentially Missable Cause of Liver Abscesses
Ben Warner, Terry Wong, and Philip Berry
Gastroenterology, Guy’s and St omas’ NHS Foundation Trust, London, UK
Correspondence should be addressed to Ben Warner; b.warner@uclmail.net
Received July ; Revised October ; Accepted November
Academic Editor: I. Michael Leitman
Copyright © Ben Warner et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cholecystocolonic stulas (CCF) due to colonic diverticulosis are a rare cause of liver abscesses. It is even rarer to simultaneously
have choledocholithiasis, another cause for liver abscesses. In this case report, we found both pathologies and emphasise the need
to study cholangiograms carefully so as not to miss alternative diagnoses.
1. Case Presentation
An -year-old man with a history of chronic diarrhoea was
admitted with severe Gram-negative sepsis, mild jaundice
(bilirubin 𝜇mol/L), and coagulopathy (INR .). Liver
function tests were also deranged (alkaline phosphatase
IU/L, alanine transferase IU/L). Computed tomogra-
phy (CT) revealed an . cm by .cm liver abscess con-
taining small amounts of gas, inammatory stranding in
both the regions of the gall bladder and hepatic exure, and
aerobilia (Figure ). e abscess was drained percutaneously
and aspirates cultured Escherichia coli.
Magnetic resonance cholangiopancreatography (MRCP)
showed a common bile duct stone. Endoscopic retrograde
cholangiopancreatography (ERCP) demonstrated an mm
common bile duct stone with preferential lling of contrast
of the le intrahepatic ducts and aerobilia (prior to sphinc-
terotomy) on the right (Figure ). Initially, the collapsed gall
bladder lled with contrast (Figure ), but in later images
contrast collected in another viscus, interpreted to be colon
(Figure ). A sphincterotomy was performed, the stone was
removed with a balloon trawl, and a double pigtail stent
was inserted. Following identication of the CCF, the patient
underwent a colonoscopy. is showed bile staining of the
transverse and ascending segments. At the hepatic exure
there was signicant diverticulosis, but no stulous opening
was seen, and tumour was excluded.
At surgery, the stula was excisable and the opening to
thecolonwassealedwithanomentalplug.is,alongwith
cholecystectomy, was performed as a one-stage procedure.
Histology of the specimen conrmed the presence of an
acutely inamed stula within the gall bladder with mucosal
transition to large bowel mucosa. ere was no dysplasia
or malignancy detected. No gall bladder stones were found.
e patient’s recovery was complicated by a hospital acquired
pneumonia from which he died weeks later.
2. Discussion
e case is rare for the fact there were two potential causes of
liver abscesses present. e presentation of sepsis, jaundice,
and choledocholithiasis led us to presume that the abscess
wascausedbycholangitisandinitialendoscopicmanagement
focussed on the stone’s removal. Even aer opacication of
the colon at ERCP, we still felt the cause of the stula to be
biliary in origin.
CCFs occur in . to .% of patients with biliary
disease typically aecting females in their th and th decades
[]. Cholecystoduodenal stulas, resulting in gall stone ileus
or Bouveret Syndrome, are more common []. It is rare for
CCFs to originate from the colon. For example, Crohn’s
disease does not stulate to the gall bladder. Most CCFs
instead develop due to gall bladder disease and gall stones,
but colonic diverticulosis has been implicated []. In this
case, the patient did not have gall bladder stones but he did
have signicant diverticulosis. Fistulation commonly occurs
at the hepatic exure due to its proximity to the gall bladder.
Uncomplicated CCFs are mostly diagnosed intraoperatively
Hindawi Publishing Corporation
Case Reports in Gastrointestinal Medicine
Volume 2016, Article ID 4803461, 3 pages
http://dx.doi.org/10.1155/2016/4803461
Case Reports in Gastrointestinal Medicine
F : CT showing liver abscess formation within the liver.
F : Cholangiogram at ERCP showing an mm common bile
duct stone with preferential lling of contrast of the le intrahepatic
ducts and aerobilia (see arrow) on the right.
presenting a challenge to surgeons who then need to convert
to open cholecystectomy [].
Diarrhoea is the most common presentation (% of
patients)duetothelaxativeeectsofbileacidsonthe
colon []. Our patient had experienced diarrhoea for some
weeks prior to admission. In retrospect, the presentation of
diarrhoea, coagulopathy (due to vitamin K malabsorption),
andaerobilia,intheabsenceofaprevioussphincterotomy,
are a previously described triad pathognomonic of CCFs [].
Gall bladder cancers can underlie some cases of CCF and
frozen specimens should be examined for this postoperatively
[].
Endoscopic closure of these stulas by over the scope
clip system (OTSC) has been described []. e presence of
diverticulosis made this method relatively contraindicated.
ERCP and sphincterotomy are thought to encourage CCF
closure although this is more relevant for cases caused by
stone disease []. In our patient, it is possible that the
combination of both a CCF and biliary stone accentuated the
formation of an abscess due to inadequate biliary drainage as
his jaundice resolved following the stone’s removal.
Bothsurgicalandconservativemanagementapproaches
have been advocated, the latter in view of many patients’
F : Cholangiogram showing collapsed gall bladder lling
with contrast (see arrow).
F : Cholangiogram showing contrast lling another viscus
interpreted to be colon.
frailties or comorbidities. In uncomplicated CCF, a one-step
procedure can be performed. For frail patients, a two-stage
procedure involving a defunctioning colostomy is an option
[]. Either way, intervention is required if there is ongoing
hepatobiliary sepsis to prevent further contamination from
colonic contents. In our patient, it was felt that he required
a denitive treatment. However, in retrospect he was frail
following a long Intensive Care Unit admission and further
physiotherapy and nutritional support could have been insti-
tuted, to improve his performance status prior to surgery.
3. Conclusion
e presence of the CCF may well have been a coincidental
nding and not contributory to the abscess. On the other
hand, the stula, if le, could have led to further biliary
sepsis. In conclusion, we highlight the importance of study-
ing cholangiograms carefully for simultaneous pathologies.
ere are several potential causes for CCFs and a colonoscopy
isadvisedtoruleoutthepresenceofdiverticulosisortumour
which would require surgical intervention.
Case Reports in Gastrointestinal Medicine
Competing Interests
None of the authors have any conict of interests.
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