Abstract
Cholecystogastric fistula is a rare biliary-enteric fistula with a variable clinical presentation. Despite modern diagnostic tools, a high index of suspicion is needed to diagnose it preoperatively. Stone migration into stomach forming gallstone bezoar is very rare. Stones more than 2.5 cm are likely to cause obstruction. We report a case of gallstone bezoar of size 9 × 5 cm lying in the stomach with a small fistulous opening in the prepyloric region of the stomach. Patient was thoroughly investigated and successfully treated with retrieval of bezoar and cholecystectomy.
Keywords: Cholecystogastric fistula, Bezoar, Biliary fistulas
Introduction
Biliary-enteric fistula following dislodgement of gallstones represents one of the late sequelae of cholelithiasis.
Case Report
A 70-year-old male patient presented with painful lump in the right hypochondriac region with fever and anorexia since 3 weeks. Except raised leucocytic count, all other biochemical investigations were within normal limits.
CT scan showed severe changes of cholecystitis, associated with fistulous communication between the gallbladder and gastric antrum.
Oesophago-gastrodudenoscopy (Fig. 1) revealed a fistulous opening in the prepyloric region with bile coming from it. A foreign body ?bezoar was seen in the body of the stomach which could not be retrieved endoscopically.
Fig. 1.
Bezoar visualised in upper GI scopy and CT scan
During laparotomy, no fistulous tract could be found. After safeguarding the CBD and duodenum, the rest of the inflammatory mass was removed from the gallbladder fossa. A mass was felt in the antrum of the stomach. Anterior gastrotomy was done and 9 × 5 × 5 cm gallstone bezoar was extracted (Fig. 2).
Fig. 2.
Retrieval of bezoar through anterior gastrotomy
Chemical analysis of the bezoar showed presence of cholesterol and calcium oxalate which goes in favour of gallstone. Histopathological findings were consistent with necrotic gallbladder wall and pericholecystic adhesions.
Discussion
Migration of gallstone through fistula to the stomach and forming a bezoar is very rare and very few cases have been reported till now [1] In most cases, the gallstone enter the duodenum via cholecystoduodenal fistula followed by retrograde migration to the stomach [2]. Small stones generally get eliminated via the stools. Stones measuring more than 2.5 cm usually produce symptoms [3]. The most common manifestation is acute obstruction (Bouveret’s syndrome). Occasionally, as in our case, the stone may get located in the antrum or body of the stomach and form a nidus for bezoar formation.
References
- 1.Tadros GM, Draganescu JM, Clarke LE, Albornoz MA. Intragastric gallstone-induced bezoar: an unusual cause of acute gastric outlet obstruction. South Med J. 2002;95(2):261–264. doi: 10.1097/00007611-200295020-00023. [DOI] [PubMed] [Google Scholar]
- 2.Shaffer RD, Smollen WJ, Klug T. Endoscopic diagnosis of asymptomatic cholecystogastric fistula. Gastrointest Endosc. 1978;24(4):179–180. doi: 10.1016/S0016-5107(78)73502-9. [DOI] [PubMed] [Google Scholar]
- 3.Kasahara Y, Umemura H, Shiraha S, Kuyama T, Sakata K, Kubota H. Gallstone ileus. Review of 112 patients in the Japanese literature. Am J Surg. 1980;140(3):437–440. doi: 10.1016/0002-9610(80)90185-3. [DOI] [PubMed] [Google Scholar]