choledochoduodenal fistulas
TRANSCRIPT
Choledochoduodenal fistula
Prof. Sherif MogawerShaimaa Elkholy
Cairo University, Egypt
Shaimaa Elkholy, M.D. Cairo University
Case presentation
• A 55 years old male patient presenting withacute onset of epigasrtic pain associated withvomiting ,rigors, chills and fever reaching upto 39 c
• The patient had history of melena 5 years agofor which he was admitted to the hospital UGIendoscopy was done to him showing pepticulcer disease
Shaimaa Elkholy, M.D. Cairo University
Case presentation
• The patient was discharged on PPI that was
prescribed to him and he was instructed to
quit smoking and stop NSAIDs but the patient
was not compliant
• On examination the patient had epigastric
and right hypochondrial tenderness
Case presentation
Shaimaa Elkholy, M.D. Cairo University
Case presentation
• Laboratory tests showed: leucocytosis (13,500) with shift to the left
• Abdominal ultrasound showed microlithiasisof the gallbladder and presence of air in the common bile duct (pneumobilia)
Case presentation
Shaimaa Elkholy, M.D. Cairo University
Choledochoduodenal fistula (CDF)
Incidence:
• It’s a very rare condition
• Accounts for about 5 % of all bilio-enteric fistulas
• Bilio-enteric fistulas:
Cholecystoduodenal most common
Cholecyscolonic
Cholecystogastric
Shaimaa Elkholy, M.D. Cairo University
Choledochoduodenal fistula (CFD)
Its rarity referred to the fact that the commonest site of duodenal ulcer is about 4 cm from the pyloric ring and CBD is about 7 cm from the pylorus
Shaimaa Elkholy, M.D. Cairo University
Choledochoduodenal fistula (CDF)
Incidence:
• Male : female ratio is 3:1
• 5th- 6th decade
• It has 2 types:
Proximal CDFs “ posterior bulb wall”
Distal CDFs “periampullary”
Shaimaa Elkholy, M.D. Cairo University
Aetiology of the spontaneous CDFs:
• Penetrating duodenal ulcer 80 % (PCDFs)
• Choledocholithiasis (DCDFs)
• Malignancies
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Presentation :
• Asymptomatic “most common”
• Ascending cholangitis
• Obstructive jaundice
• UGIB “rare”
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Imaging
X-RAY
Pneumobilia
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Imaging
U/S
Pneumobilia
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Imaging
C.T.
Pneumobilia
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Diagnosis :
• Endoscopy
UGI
ERCP
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
choledochoduodenal fistula and Cholangiogram was demonstrated by introducing contrast medium into the fistula
Shaimaa Elkholy, M.D. Cairo University
Management :
• Debate of MEDICAL versus SURGICAL
• Medical:
Asymptomatic or high risk
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Management :
• Surgical:
• Used to be the main line “prophylactic”
• Reserved for failed medical, bleeding & biliary obstruction
Laparoscopic surgery
Vagotomy and gasterojejonostomy
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Management :
• Other modalities
Endoscopic closure
over -the scope -clips
Choledochoduodenal fistula (CDF)
Shaimaa Elkholy, M.D. Cairo University
Take home message
• CDFs rare sequel for long standing duodenal ulcer
• CDFs should be bared in mind when the patient starts to develop unusual symptoms e.g. jaundice , cholangitis
• Adequate biliary drainage should be ensured before management
• Endoscopic closure using over the scope clip may be the modality of choice
Shaimaa Elkholy, M.D. Cairo University