Choledochoduodenal fistula due to peptic duodenal ulcer diagnosed by X-barium meal study: interest of medical treatment
Mohamed Ali Chaouch, Karim Nacef, Mossab Ghannouchi, Mohamed Ben Khalifa, Asma Chaouch, Molk Abdelkafi, Saida Jerbi, Moez Boudokhane
The Pan African Medical Journal. 2018;29:177. doi:10.11604/pamj.2018.29.177.15043

Create an account  | Log in
AFENET CONF 2018 AFENET CONF 2018
"Better health through knowledge sharing and information dissemination "

Case report

Choledochoduodenal fistula due to peptic duodenal ulcer diagnosed by X-barium meal study: interest of medical treatment

Cite this: The Pan African Medical Journal. 2018;29:177. doi:10.11604/pamj.2018.29.177.15043

Received: 06/02/2018 - Accepted: 01/03/2018 - Published: 26/03/2018

Key words: Choledochoduodenal fistula, duodenal ulcer, biliary fistula, barium meal

© Mohamed Ali Chaouch et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Available online at: http://www.panafrican-med-journal.com/content/article/29/177/full

Corresponding author: Mohamed Ali Chaouch, Department of General Surgery, Tahar Sfar Hospital, Mahdia, Tunisia (Docmedalichaouch@gmail.com)


Choledochoduodenal fistula due to peptic duodenal ulcer diagnosed by X-barium meal study: interest of medical treatment

Mohamed Ali Chaouch1,&, Karim Nacef1, Mossab Ghannouchi1, Mohamed Ben Khalifa1, Asma Chaouch1, Molk Abdelkafi2, Saida Jerbi2, Moez Boudokhane1

 

1Department of General Surgery, Tahar Sfar Hospital, Mahdia, Tunisia, 2Department of Radiology, Tahar Sfar Hospital, Mahdia, Tunisia

 

 

&Corresponding author
Mohamed Ali Chaouch, Department of General Surgery, Tahar Sfar Hospital, Mahdia, Tunisia

 

 

Abstract

Peptic ulcer complication has decreased over le last years. Spontaneous bilio-digestive fistulas, in the absence of primary biliary disease, remain a very unusual complication of the upper digestive tract. The choledochoduodenal fistula is an extremely rare entity which can be caused by a duodenal peptic ulcer. It appears with the symptoms of peptic ulcer disease. They are diagnosed incidentally on radiological exams. It was suspected after finding pneumobilia on abdominal ultrasound and confirmed by X-barium meals study. The purpose of this observation is to report the case of a patient presenting a choledochoduodenal fistula diagnosed by X-barium meal to underline the importance of this radiological exam to diagnose this disease and to insist on the conservative treatment for choledochoduodenal fistula caused by a duodenal peptic ulcer. The prognosis of patients treated medically is good, although the fistula can remain asymptomatic. Angiocholitis and biliary sequelae remain rare and do not warrant prophylactic surgical treatment.

 

 

Introduction    Down

Internal and spontaneous bilio-digestive fistulas, in the absence of primary biliary disease, remain a very unusual complication of the upper digestive tract. They are largely dominated by cholecystoduodenal fistulas mainly caused by cholelithiasis, which account 90% of bilio-digestive fistulae [1, 2]. A choledochoduodenal fistula (CDF) is an extremely rare entity which can be caused by a duodenal peptic ulcer. Most choledochoduodenal fistulas are diagnosed incidentally by hepato-biliary radiological and endoscopic investigations. The purpose of this observation is to report the case of a patient presenting a CDF diagnosed by X-barium meal to underline the importance of this radiological exam to diagnose this disease and the performance of conservative treatment for CDF caused by a peptic duodenal ulcer.

 

 

Patient and observation Up    Down

A 59-year-old man suffering for 9 months of epigastric pain, retro-sternal burns and vomiting. This symptomatology is relieved by proton pump inhibitors. The patient had similar episodes in the past that were treated with Cimetidine for a suspected duodenal ulcer without endoscopic control. On physical examination, the patient was afebrile with mild tenderness in the epigastrium. Biological examinations reveal leukocytosis (12500 cells / mm3) with 80% neutrophils without cholestasis and hepatic cytolysis. The abdominal ultrasound showed pneumobilia (the presence of air in the biliary tree) in the absence of dilation of the biliary tract. There were no stones in the gallbladder. Oeso-gastroduodenal endoscopy revealed a duodenal bulb ulcer with erythematous lesions all around. X-barium meal confirmed the existence of a CDF by objectifying a simultaneous opacification of the biliary tract (Figure 1). The diagnosis of CDF due to a bulb peptic ulcer was retained. The decision was to manage the patient conservatively. We opted for an anti-ulcer medical treatment. The evolution was eventful with a clear improvement of the initial symptomatology. An oeso-gastroduodenal endoscopy performed after two months of medical treatment confirm the disappearance of the duodenal ulcer and the choledochoduodenal fistula. The patient remains asymptomatic after 1-year follow-up.

 

 

Discussion Up    Down

CDF is the abnormal communication between the lower end of the main bile duct and the first duodenal portion [3]. It occurs at the posterior duodenal bulb wall in most cases but occurring in the anterior duodenal bulb wall remain possible. They represent between 3.5% and 8,6% of all biliodigestive fistulas and about 3% are caused by peptic ulcer [4-6]. This affection is uncommon, there were about 80 cases reported in the literature according to publications in Medline database. In 1840, Long was the first to describe a CDF caused by duodenal ulcer [7]. It is underestimated given the large number of asymptomatic CDF. That is why the most cases are incidentally discovered and the preoperative diagnoses still difficult [8]. This affection is more common in men than women, this is due to the frequency of duodenal ulcer disease in men. While fistulas secondary to gallstones are more common in women [9]. Duodenal peptic ulcer communicates usually duodenal bulb with biliary tract into the common bile duct. CDF can be caused by many affections: cholelithiasis, choledocholithiasis, iatrogenic injury, duodenal diverticula, para duodenal abscess, Crohn's disease, liver transplantation, metallic biliary stent placement, cancer of the upper digestive tract and even duodenal tuberculosis [4, 10, 11]. In recent years, the duodenal peptic ulcer is becoming a rare etiology of these CDFs, because of the control and the effectiveness of ulcer drugs than before [4]. It is most often asymptomatic and does not have specific clinical symptoms. Clinical signs are the same of the duodenal peptic ulcer. Angiocholitis, jaundice or anomaly of biological liver exams are rare [1, 10]. For diagnosing CDF, imaging procedures are needed. In some cases, the presence of an internal biliary fistula can be suggested by the findings of pneumobilia, atrophic gallbladder and biliary stones [12]. The accidental discovery of air within the biliary tree on the abdominal X-ray [11] or reflux of contrast in the biliary tree on X-barium meal must suspect the diagnosis of CDF [3]. Oeso-gastroduodenal endoscopy allows the direct visualization of duodenal ulcer, bulbar stenosis and CDF. It's a great way to diagnose in experienced hands. On the other hand, the ERCP with opacification of the fistulous tract is possible but it can be difficult because of the associated ulcer and duodenal deformity but it can be performed with a pediatric endoscope [2, 13]. The abdominal ultrasound can highlight the pneumobilia which presented in our patient and confirm the absence of cholelithiasis that may be the cause of CDF. This pneumobilia is helpful for the diagnosis, but it is present only in 14 to 58% of cases [14]. Moreover, its absence does not eliminate it. The management depends essentially on the etiology of the fistula. Treatment of CDF caused by duodenal peptic ulcer is controversial. Some authors believe that prophylactic surgery is still indicated, others insist that treatment should initially be medical and then surgical in case of failure [3, 4, 14, 15]. However, with the advent of potent anti-ulcer drugs, healing of ulcers has been shown to be associated with healing and closing this type of fistulas like in our case [2]. In addition, patients with high surgical risk treated medically seem to be symptoms relieving in most cases [16]. Some studies suggest that asymptomatic patients probably should not receive treatment, especially surgery. In addition, the risk of angiocholitis or stenosis of the main bile duct is minimal [14, 15]. The endoscopic stent of the bile ducts combined with antiulcer therapy allows the healing of ulcers and fistula. In the past, surgical approaches have been the treatment of choice. Currently, surgery is indicated in patients with a complication of duodenal ulcer: angiocholitis, perforation, bleeding, stenosis or in the absence of improvement by medical treatment [1, 10]. According to the literature, the prognosis of the patients treated medically is good, although the fistula can remain patent [13]. Angiocholitis and biliary sequelae remain rare and do not warrant prophylactic surgical treatment. Then, treatment should focus on the ulcer peptic disease then correction of CDF.

 

 

Conclusion Up    Down

Spontaneous bilio-digestive fistulas, in the absence of primary biliary disease, remain a very unusual complication of the upper digestive tract. CDF due to the peptic duodenal ulcer is becoming more and rarer. It appears with non-specific symptoms. It is diagnosed generally after radiological or endoscopic investigations. The prognosis of patients treated medically is good. Angiocholitis and biliary sequelae remain rare and do not warrant prophylactic surgical treatment. Then we insist on the conservative treatment for CDF caused by a duodenal peptic ulcer.

 

 

Competing interests Up    Down

The authors declare no competing interest.

 

 

Authors’ contributions Up    Down

This list of authors contains all the surgeons that have operated the patients in this series.

 

 

Figure Up    Down

Figure 1: barium meal study demonstrating deformed duodenal bulb and reflux of contrast into the biliary tract

 

 

References Up    Down

  1. Feller ER, Warshaw AL, Schapiro RH. Observations on management of choledochoduodenal fistula due to penetrating peptic ulcer. Gastroenterology.1980; 78(1): 126-131. PubMed | Google Scholar

  2. Laajam MA et al. Choledochoduodenal fistula: a vanishing complication of peptic ulcer revisited. Annals of Saudi medicine. 1994; 14(3): 254. Google Scholar

  3. Jaballah S, Sabri Y, Karim S. Case report: choledochoduodenal fistula due to duodenal peptic ulcer. Digestive diseases and sciences. 2001; 46(11): 2475-2479. PubMed | Google Scholar

  4. Wu M et al. Choledochoduodenal fistula in Mainland China: a review of epidemiology, etiology, diagnosis and management. Annals of surgical treatment and research. 2015; 89(5): 240-246. Google Scholar

  5. Fedidat R et al. Choledochoduodenal fistula: an unusual case of pneumobilia. BMJ case reports. 2014; 2014: bcr2014206798. PubMed | Google Scholar

  6. Stagnitti F et al. Spontaneous biliodigestive fistulae: the clinical considerations, surgical treatment and complications. Il Giornale di chirurgia. 2000; 21(3): 110-117. Google Scholar

  7. Long J. On the post-mortem appearances found after burns. Lond Med Gaz. 1840; 25: 743. Google Scholar

  8. Luu MB and Deziel DJ. Unusual complications of gallstones. Surgical Clinics. 2014; 94(2): 377-394. PubMed | Google Scholar

  9. Michowitz M et al. Choledochoduodenal fistula: a rare complication of duodenal ulcer. American Journal of Gastroenterology. 1984; 79(5): 416-20. PubMed | Google Scholar

  10. Kourias B. Spontaneous gastrointestinal biliary fistula complicating duodenal ulcer. Surg Gynec Obstet. 1964 Nov; 119:1013-1018. PubMed | Google Scholar

  11. Karthikeyan V et al. Spontaneous choledochoduodenal fistula with tuberculous duodenal ulceration. The Annals of the Royal College of Surgeons of England. 2014; 96(1): e01-e02. Google Scholar

  12. Yang D et al. Laparoscopic treatment of an upper gastrointestinal obstruction due to Bouveret's syndrome. World journal of gastroenterology WJG. 2013; 19(40): 6943. Google Scholar

  13. Naga M and Mogawer M. Choledochoduodenal fistula: a rare sequel of duodenal ulcer. Endoscopy. 1991; 23(05): 307-308. PubMed | Google Scholar

  14. Dewulf E et al. L'attitude thérapeutique dans les fistules cholédocoduodénales compliquant l'ulcère duodénal. Journal de chirurgie. 1987; 124(1): 19-23. Google Scholar

  15. Jorge A et al. Choledochoduodenal fistulas. Endoscopy. 1991; 23(02): 76-78. Google Scholar

  16. Xeropotamos N et al. Choledochoduodenal fistula: an unusual complication of penetrated duodenal ulcer disease. Annals of Gastroenterology. 2004; 17(1): 104-108. PubMed | Google Scholar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


The Pan African Medical Journal articles are archived on Pubmed Central. Access PAMJ archives on PMC here

Volume 31 (September - December 2018)

Article tools

Keywords

Choledochoduodenal fistula
Duodenal ulcer
Biliary fistula
Barium meal

Rate this article

Altmetric

PAMJ is a member of the Committee on Publication Ethics
Next abstract

PAMJ is published in collaboration with the African Field Epidemiology Network (AFENET)
Currently tracked by: DOAJ, AIM, Google Scholar, AJOL, EBSCO, Scopus, Embase, IC, HINARI, Global Health, PubMed Central, PubMed/Medline, Ulrichsweb, More to come . Member of COPE.

ISSN: 1937-8688. © 2018 - Pan African Medical Journal. All rights reserved