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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 85-87

UGI bleed- A rare presentation of carcinoma gall bladder with cholecystoduodenal fistula


Department of Medicine, Jorhat Medical College, Jorhat, India

Date of Submission08-Jul-2022
Date of Acceptance16-Aug-2022
Date of Web Publication23-Nov-2022

Correspondence Address:
Dr. Karishma Das
Department of Medicine, Jorhat Medical College, Jorhat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajoim.ajoim_11_22

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  Abstract 

Upper GI bleeding(UGIB) is defined as bleeding derived from a source proximal to the ligament of Treitz. It is a life threatening condition. Bilioenteric fistulas are abnormal communication between the bile duct system and the gastrointestinal tract that occurs spontaneously and usually occurs as a rare complication of untreated gallstone in majority of cases. Cholecystoduodenal fistula(CDF) as a cause of upper GI bleeding is an extremely rare event. It has been theorized that a cholecystoduodenal fistula may lead to development of carcinoma gall bladder due to chronic reflux of duodenal contents. High index of clinical suspicion is required to make a diagnosis.

Keywords: Carcinoma gall bladder(CA Gb), cholecystoduodenal fistula(CDF), duodenal ulcer(DU), upper GI bleeding(UGI Bleed)


How to cite this article:
Das K, Kar S, Pegu UR, Hazarika L. UGI bleed- A rare presentation of carcinoma gall bladder with cholecystoduodenal fistula. Assam J Intern Med 2022;12:85-7

How to cite this URL:
Das K, Kar S, Pegu UR, Hazarika L. UGI bleed- A rare presentation of carcinoma gall bladder with cholecystoduodenal fistula. Assam J Intern Med [serial online] 2022 [cited 2022 Nov 29];12:85-7. Available from: http://www.ajimedicine.com/text.asp?2022/12/2/85/361823


  Introduction Top


Upper GI bleeding is defined as bleeding within the intraluminal gastrointestinal tract from any location between the upper esophagus to the duodenum at the ligament of Treitz. It usually presents with hematamesis,(”coffee ground” vomitus) and/or melaena. It is one of the most important medical emergencies worldwide. Peptic ulcer disease is the most common cause(50%) followed by esophagitis and erosive gastritis whereas varices are the most common cause in patients with chronic liver disease.[1] Other relatively uncommon causes include vascular ectasias and Dieulafoy’s lesion. CDF is the most common biliary-enteric fistula. Upper GI bleeding caused by cholecystoduodenal fistula is rare with only few cases reported in literature. It has been theorized that a cholecystoduodenal fistula may represent a significant risk factor in the development of gall bladder carcinoma because of chronic reflux of duodenal contents.

Here we are reporting a case of cholecystoduodenal fistula with carcinoma gall bladder presenting as upper GI bleeding.


  Case Report Top


BRIEF HISTORY

An 80 year old male patient presented with multiple episodes of hematamesis and melaena. He also complained of upper abdominal discomfort, decreased appetite, easy fatiguability and weight loss since the past 4months.


  On Examination Top


The patient was ill looking, afebrile; pallor was present; cyanosis, clubbing, edema and lymphadenopathy were absent. The pulse rate was 110bpm and the Blood pressure was 90/60mmhg. The respiratory rate was 20/min.

On per abdomen examination,there was tenderness over the epigastrium and right hypochondrium,peristaltic sounds were increased. CNS, CVS and Respiratory system examination were normal.

Treatment

Our patient was given conservative treatment with pantoprazole infusion, IV fluids and 2 units of blood was transfused.


  Investigations Top


Hb-6.1g/dl; TC-9200; DLC-N76.4L17.5M3.5E2B0.4; Creatinine-0.92 mg/dl; AST-25U/L; ALT-11U/L; Albumin-2.52g/dl

UGI Endoscopy revealed a black base ulcer at the first part of duodenum[as shown in [Figure 1]]
Figure 1: Endoscopic image. Esophagogastroduodenoscopy revealed a black base ulcer at the D1 segment

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USG Abdomen- Ultrasonographic loss of GB contour and GB liver interface with air foci and intraluminal calculus.

CECT Abdomen- Possible mitotic growth in GB-liver interface involving IVb and V causing Cholecystoduodenal fistula[as shown in [Figure 2]]
Figure 2: CECT Abdomen showing mitotic growth at GB liver interface and fistulous connection between gallbladder and duodenum

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Minimal ascites with bilateral pleural effusion

USG guided FNAC from lesion in gall bladder and liver interface showed sheets and clusters of malignant cells in a hemorrhagic background. These cells have moderate amount of cytoplasm and pleomorphic hyperchromatic nuclei. The features are consistent with carcinoma.


  Discussion Top


Upper GI bleeding is a very common life threatening condition. Atleast 5% of all the admission from emergency department in India is due to UGI bleed. The incidence of UGI bleed ranges from 50 to 150/100,000 population annually worldwide.[2] In a study done in South India, the most common cause of UGI Bleed was varices followed by peptic ulcer disease.[3] In a study done in Northeastern India, the most common cause of UGI bleed was peptic ulcer diease followed by variceal rupture.[4]

Cholecystoduodenal fistula rarely causes upper GI bleeding. A thorough search of medical literature revealed only 11 case reports published in. The first reported case of cholecystoduodenal fistula presenting as upper GI bleed was reported in 1967 from Massachusetts General Hospital.[5] Gaetano La Greca et al. also reported a similar case in 2008 where a patient with UGI bleed had a duodenal ulcer with penetration/fistulisation in common bile duct associated with perforation of gall bladder with intrahepatic abscess and erosion of gastroduodenal artery.[6]

Bilioenteric fistulas are abnormal communication between the bile duct system and the gastrointestinal tract that occurs spontaneously and is a rare complication of an untreated gallstone in majority of cases.

It has been theorized that a cholecystoduodenal fistula may represent a significant risk factor in the development of gall bladder carcinoma because of the chronic reflux of duodenal contents including pancreatic juice. Once carcinoma gallbladder develops,the patient has a poor prognosis. Takharo Sanada et al. reported a case of carcinoma gallbladder which progressed to duodenal wall through a cholecystoduodenal fistula.[7]

As cholecystoduodenal fistula is a rare cause of massive upper GI bleed, a high index of clinical suspicion should always be in mind. Once diagnosis is made,surgery remains the most effective treatment. Our patient,however,received only palliative care due to advanced course of the disease. To the best of our knowledge,this is the first reported case of carcinoma gall bladder with cholecystoduodenal fistula as a cause of upper GI bleed in this region. We believe that this case highlights the importance of clinical suspicion and the role of CT imaging as complementary tool to aid in diagnosis of cases with UGI bleed and nonsatisfactory endoscopic finding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2008;22:209-24.  Back to cited text no. 1
    
2.
Fallah MA, Prakash C, Edmundowicz S. Acute gastrointestinal bleeding. Med Clin North Am 2000;84:1183-208.  Back to cited text no. 2
    
3.
Mahajan P, Chandail VS. Etiological and endoscopic profile of middle aged and elderly patients with upper gastrointestinal bleeding in a tertiary care hospital in North India: A retrospective analysis. J Midlife Health 2017;8:137-41.  Back to cited text no. 3
    
4.
Chetia K, Borah RK. Upper Gastrointestinal bleeding in a tertiary care center in North East India: A retrospective study. Int J Adv Res 2020;8:559-63.  Back to cited text no. 4
    
5.
Corry RJ, Mundth ED, Bartlett MK. Massive upper-gastrointestinal tract hemorrhage. A complication of cholecystoduodenal fistula. Arch Surg 1968;97:531-2.  Back to cited text no. 5
    
6.
La Greca G, Grasso E, Sofia M, Gagliardo S, Barbagallo F. [Complicated duodeno-biliary fistula in bleeding duodenal ulcer: Case report an literature review]. Ann Ital Chir 2008;79:57-61.  Back to cited text no. 6
    
7.
Sanada T, Baba H, Ohba A, Wakabayashi M, Ebana H, Nakamura H, et al. [Gallbladder carcinoma, progressed along cholecystoduodenal fistula–a case report]. Gan to Kagaku Ryoho 2010;37:2717-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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  In this article
   Abstract
  Introduction
  Case Report
  On Examination
  Investigations
  Discussion
   References
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