27 March 2019: Articles 
Choledochoduodenal Fistula Secondary to Peptic Ulcer Disease: A Case Report
Challenging differential diagnosis, Rare coexistence of disease or pathology
Antoine Kachi DG 1,2, Mouhammad Kanj ABCDEF 1, Charif Khaled ABCE 1, Chady Nassar A 1, Charbel Bou Rached A 1, Alaa Kansoun ABCDEF 1*DOI: 10.12659/AJCR.915600
Am J Case Rep 2019; 20:398-401
Abstract
BACKGROUND: Choledochoduodenal fistula is an uncommon complication secondary to peptic ulcer disease. Determining this diagnosis is challenging especially when confronted with unspecific physical and radiological findings.
CASE REPORT: Here we report a case of a 29-year-old Ethiopian female who presented to Geitaoui University Hospital in Beirut, Lebanon with epigastric pain and was diagnosed to have of choledochoduodenal fistula.
CONCLUSIONS: Choledochoduodenal fistula is a rare complication of duodenal ulcer and this case report may help clinicians to identify suspected cases of this entity with similar presentations.
Keywords: Biliary Fistula, Intestinal Fistula, Peptic Ulcer, Cholangiopancreatography, Endoscopic Retrograde, Cholangiopancreatography, Magnetic Resonance, Common Bile Duct Diseases, Duodenal Diseases
Background
Internal biliary fistulas represent only 2% of all biliary diseases [1]. The most commonly reported types of fistula in order of frequency are: cholecystoduodenal, choledochoduodenal, cholecystocolonic, and cholecystogastric [1,2]. These abnormal communications are usually related to biliary lithiasis [3]. Choledochoduodenal fistula accounts for 5–25% of all internal biliary fistulas [4]. Mostly duodeno-biliary fistula is caused by gall stones and subsequent inflammation of the bile duct; however, other causes, including duodenal ulcer, are possible [5]. Rarely, an entero-biliary fistula can be attributed to a benign ulcer [6], while giant peptic ulcers may perforate into the common bile duct [7]. Notably, duodenal ulcer
Case Report
We present a case of a 29-year-old Ethiopian female, who had recurrent episodes of abdominal pain, and who presented to the Emergency Department complaining of severe epigastric pain. Her pain had been increasing in intensity for the past couple of days, and was associated with nausea and vomiting. Upon presentation, the patient was febrile and icteric. Abdominal examination revealed localized epigastric tenderness. Initial blood workup revealed leukocytosis, elevated C-reactive protein (CRP) and disturbed liver function tests as shown in Table 1.
Abdominal ultrasound showed a distended gallbladder containing micro-lithiasis with dilatation of the intra and extra-hepatic bile ducts. Moreover, magnetic resonance cholangiopancreatography showed diffuse dilatation of intra and extra-hepatic bile ducts in the absence of stones or obstacles along with multiple hypointense images at the level of the intra-hepatic bile ducts, consistent with aerobilia as shown in Figure 1.
An attempt to do endoscopic retrograde cholangiopancreatography failed because the duodenum could not be bypassed due to the inflammatory process in the pyloric region as shown in Figure 2.
The examination was completed by an upper gastro-intestinal series with gastrografin swallow for better assessment of the pyloric stenosis. The examination revealed an extravasation of the contrast from the base of the duodenum at around 7 mm ulcer to the hepato-biliary tree along with a completely deformed duodenal bulb as shown in Figure 3.
The patient was diagnosed as having cholangitis secondary to a choledochoduodenal fistula. Broad spectrum antibiotic therapy was started. The patient underwent a laparotomy and a choledochoduodenal fistula was confirmed. We decided to do a cholecystectomy, a gastro-jejunostomy, and a hepaticojejunostomy. She recovered well, and was discharged home with an uneventful post-operative period.
Discussion
STUDY LIMITATIONS:
This study aimed to pinpoint a rare complication of a relatively common disease, however, it provides little evidence concerning the treatment plan. It is a case report that needs to be endorsed by other studies higher in quality to allow us to know more about managing this condition.
Conclusions
Choledochoduodenal fistula is a rare complication of duodenal ulcer. Patients may present with non-specific clinical symptoms, which makes the diagnosis difficult. Pneumobilia and the presence of contrast in the biliary tree should always alert the clinician to the possibility of choledochoduodenal fistula. Surgery should be considered for refractory cases. This case report is a reminder of a rare complication for a relatively common disease: peptic ulcer disease.
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