Choledochoduodenal fistula complicating duodenal ulcer disease (a report of 3 cases).

P Shah, R Ramakantan 
 

Correspondence Address:
P Shah

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::   Introduction

Only 5% of all choledochoduodenal fistula (CDF) are the consequence of complicated duodenal ulcer disease[1]. They often present without specific clinical symptoms and may be incidentally picked up on upper GI radiographic study or endoscopy. We had 3 such cases diagnosed in our hospital and they are being reported here.

::   Case report

Case 1:

A 55-year-old male presented with epigastric burning pain relieved with meals and of duration 5 years.; There was no history of right upper quadrant pain or of fever.

An upper GI endoscopy revealed a deformed duodenal cap. No fistulous communication was seen. However, on an upper G1 examination performed 4 days later (see [Figure:1]) in addition to the scarred cap, free filling of the retro-and supra-duodenal portions of the common bile duct (CBD) and the intrallepatic biliary radicals was seen. Free emptying of barium from the biliary tract was seen on the follow-up film.

The patient was advised to continue conservative treatment for his ulcer disease.

Case 2:

A 40-year-old male patient presented with a 2 year history of upper abdominal pain associated with vomiting following meals. Upper GI endoscopy showed a narrowing of the pylorus; the duodenal cap could not be entered. Barium study of the upper GI tract (see [Figure:2]) showed no significant gastric outlet obstruction, a scarred duodenal cap and opacification of the CBD through a long fistulous tract leading from the duodenal cap. No specific change in the conservative treatment was deemed necessary, as the patient had no specific symptoms related to the fistula.

Case 3:

A 14-year-old boy came with a history of colicky upper abdominal pain with no specific relieving or aggravating factors. A small bowel series with films of the duodenum without abdominal compression did not show any abnormality. However, at tile upper GI endoscopy, the duodenal cap was seen to be scared and a large ulcer crater leading to a tract could be seen. This was cannulated and injection of contrast revealed (see [Figure:3]) opacification of the biliary tract. This patient too was managed conservatively for duodenal ulcer disease.

::   Discussion

CDF, produced as a consequence of chronic ulcer disease of the duodenal cap constitutes only 5% of the cases producing biliary enteric fistulas[1]. Until 1986 only 8 cases have been reported in Indian literature[2],[4],[5]. The reason for the rarity of this condition becomes apparent when one realises that a duodenal ulcer most typically occurs about 4 cm distal to the pylorus whereas the CBD is about 7 cm distal to the pylorus[3]. For most part, these fistulas are incidental findings at upper GI studies and seldom produce any specific symptoms; the presence of symptoms being related to the obstruction for emptying of the biliary tract into the duodenum[3].

None of our 3 patients had symptoms related to the fistula itself.

The diagnosis of CDF is invariably apparent on upper GI examination with barium. The findings become conclusive especially if the distal part of the CBD is not seen at this time. In 2 of our 3 patients, radiography demonstrated a fistula on the GI series. However, in the 3rd patient (case 3), the barium study did not show the fistula, apparently be cause no compression films were obtained. In this patient, contrast injection into the fistula following endoscopic cannulation elegantly demonstrated the pathology. To our knowledge, this is the first such demonstration of a CDF produced by ulcer disease. In patients with symptoms related to the fistula such as repeated attacks of cholangitis antrectomy with vagotomy is recommended[3]. In none of our patients this was indicated and hence no surgery was offered.

In conclusion, biliary enteric fistulas produced by ulcer disease are a rare occurrence - often noted incidentally at upper GI examinations. Radiologic and endoscopic studies supplement each other in their diagnosis. The diagnosis of such fistulas often does not alter further management unless the complication of cholangitis due to obstruction is present, in which case, surgical intervention[1] is indicated.

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