We report the case of a 60-year-old man presenting with a non-healing sinus on the upper abdominal wall. Investigations suggested a cholecystocutaneous fistula secondary to chronic calculous cholecystitis, which was confirmed at surgery. The patient is well 20 months after cholecystectomy and excision of the fistula tract.
Due to the early diagnosis and prompt treatment, the incidence of external and internal fistulas as a complication to gall stones has drastically decreased. Around 21cases1 of external cholecystocutaneous fistulas have been reported over the last six decades. We present a case of gall stone disease manifesting as a persistent abdominal wall sinus due to a cholecystocutaneous fistula. To our knowledge there is no case report from India.
A sixty year old male, hailing from eastern India, presented with a discharging sinus on the anterior abdominal wall of six months duration. The discharge was intermittent in nature. The patient had a history of recurrent upper abdominal pain a year earlier, which had settled with conservative treatment in his native place. He had been treated with anti- tubercular treatment for the sinus without any response. On examination he had a sinus on the anterior abdominal wall at the level of the eighth costal margin, which was discharging seropurulent fluid. A sinogram revealed a 2 cm sinus in the abdominal wall. A biopsy of the sinus tract did not reveal any specific pathology.
A CT scan of the lower chest and abdomen was done. It showed a thickened, calcified gall bladder wall with multiple gallstones, which was adherent to the anterior abdominal wall just below the sinus tract.
|Fig. 1 : CT scan showing gall bladder with stones (arrow) and fistula (arrow).
The peritoneum and abdominal wall in this area was thickened. Rest of the surrounding organs and ribs were normal.
In view of the high suspicion of the gall bladder being the cause of the sinus, the patient was taken up for surgery. Intraoperatively, when a probe was introduced into the sinus tract, it entered the gall bladder in the fundal region. A cholecystectomy was performed and the sinus tract was excised. The gall bladder wall was thickened and contained multiple stones. Histopathology showed changes of chronic cholecystitis with no evidence of tuberculosis or malignancy. After surgery, the sinus had healed completely. Twenty months after surgery, the patient is well without evidence of recurrence.
Cholecystocutaneous fistulas were often reported in early surgical literature. The first case was reported as early as 1670 by Thilesus. Courvoisier reported 169 cases of cholecystocutaneous fistulas out of 499 cases of gall bladder perforation. In 1949, Henry and Orr added 36 cases bringing the grand total to 205. Around 22 cases have been reported sporadically thereafter.
Gall stones block the flow of bile leading to increased pressure within the gall bladder resulting in mural necrosis and perforation. Perforations of the gall bladder can present as acute peritonitis, gall bladder abscesses or form fistulae. External fistulae usually arise from the fundus of the gall bladder. Often painless, the openings of these fistulas are most often located in the right upper abdomen though; other sites such as right iliac fossa, the gluteal region have been reported.1
The external opening of the fistula can be mistaken for a pyogenic granuloma, cellulitis, infected epidermal inclusion cyst, metastatic carcinoma or as in our case a tuberculous sinus. The discharge from the fistula is often purulent or mucoid. It may be bilious if the cystic duct is patent but that is rare.2 Gall bladder tuberculosis, though rare, mostly presents as a biliary stricture or chronic cholecystitis3 with acute exacerbations. However it is not reported to present with a sinus or fistula. Abdominal wall sinuses as a result of gallstones have been reported following spillage of the gall bladder contents during laparoscopic cholecystectomy.4 The mechanism is due to the persistence of gallstones or stone fragments in the abdominal wall that acts as a foreign body or by abscess formation with resultant erosion and fistula formation. Imaging plays an important role in the diagnosis of these fistulae. Gall stones can be diagnosed by ultrasonography. The diagnosis of a cutaneous fistula however may be confirmed by a fistulogram. CT imaging can help visualize the gall bladder, the fistula and the adjoining structures.
Although rare, the possibility of a cholecystocutaneous fistula should be considered in any patient who has a discharging sinus in the abdominal or chest wall in the gall bladder region, especially those hailing from high endemic areas with a history of biliary pain.
- Vasanth A, Siddiqui A, O’Donnell K. Spontaneous Cholecystocutaneous Fistula. South Med J 2004; 97 (2) : 183-5.
- Rosario P, Gerst P, Prakash K, Katter H. Cholecystocutaneous fistula: An unusual presentation. Am J Gastroenterol 1990; 85 :
- Banerjee S, Sen S. Tuberculosis of the gall bladder. J Indian Med Assoc 2003; 101(9) : 556-7.
- Pavlidis TE, Papaziogas BT, Koutelidakis IM, Papaziogas TB. Abdominal wall sinus due to impacting gallstone during laparoscopic cholecystectomy: an unusual complication. Surg Endos 2002; 16 (2) : 360.
COMPUTER-AIDED DETECTION IN SCREENING MAMMOGRAPHY
Since its approval by the Food and Drug Administration, computer-aided detection has come into use for screening mammography at many facilities. The authors of this observational study of almost 430,000 mammograms found that the use of computer-aided detection reduced the accuracy of mammography and that its systemwide use would increase the annual cost of mammography by an estimate $550 million in the United States.
N Engl J Med 2007; 356 : 1398
*Associate Professor, **Resident, Department of Ophthalmology, T.N.M.C and B.Y.L. Nair Hospital, Mumbai - 400 008.