Warren Alpert School of Medicine, Brown University Providence, RI, United States
Daniel Marino, MD, MBA, Breton Roussel, MD, Yuchen Liu, MD, April Whitaker, MD, Ross Taliano, MD, Zilla Hussain, MD Warren Alpert School of Medicine, Brown University, Providence, RI
Introduction: Cholecystogastric fistulas are uncommon entities most often arising as a late complication from cholecystitis or cholelithiasis. We report a case of a malignant cholecystogastric fistula resulting in a life-threatening gastrointestinal bleed.
Case Description/Methods: A 69-year-old female with past medical history of deep vein thrombosis (DVT) on warfarin presented with fatigue. She denied abdominal pain, nausea, vomiting, fever, chills, melena or hematochezia. Patient denies other constitutional symptoms as well including dizziness, lightheadedness, chest pain, or shortness of breath. Labs demonstrated a microcytic anemia with a hemoglobin of 6.9, INR 2.3, and elevated troponin of 47. Computed tomography (CT) of the abdomen and pelvis showed a diffusely thickened and nodular gallbladder wall, intramural air, and loss of fat planes between the liver, pylorus and first portion of the duodenum suspicious for cholecystogastric fistula (Figure A). Patient was initiated on heparin therapy for NSTEMI and subsequently developed melena. Esophagogastroduodenoscopy (EGD) revealed malignant appearing duodenal ulcer with a high-risk visible vessel that spontaneously started bleeding (Figures B-C) which despite endoscopic intervention with local epinephrine injection, required interventional radiology embolization to achieve hemostasis. Abdominal MRI showed a thickened gallbladder with heterogeneous hypoenhancement suggestive of gallbladder neoplasm with associated fistulous invasion of the proximal enteric tract at the distal stomach and proximal duodenum (Figure D). Pathology of CT guided biopsy of the gallbladder showed poorly differentiated malignant cells and immunohistochemical strain positivity for CK7, CDX2, along with Gata 3 negativity suggesting an adenocarcinoma of upper GI origin (Figures E-F). Per patient preference, she was transitioned to hospice care.
Discussion: Cholecystogastric fistulas are often asymptomatic or present with epigastric pain, vomiting, or gastric outflow obstruction. There are only a few reported cases of gastrointestinal hemorrhage resulting from cholecystogastric fistula. This case highlights a malignant cholecystogastric fistula with the initial presenting symptom as a gastrointestinal hemorrhage. Given its rarity, there is little data on the prognosis and natural history of a malignant cholecystogastric fistula.
Figure: Figure A-CT of the abdomen with findings suspicious for cholecystogastric fistula. Figure B-Malignant appearing duodenal ulcer. Figure C-Presence of active bleeding. Figure D-MRI showing gallbladder neoplasm with fistulous invasion into the distal stomach and proximal duodenum. Figures E-F-Stains positive for CK7 and CDX2 suggesting adenocarinoma of upper gastrointestinal origin.
Daniel Marino indicated no relevant financial relationships.
Breton Roussel indicated no relevant financial relationships.
Yuchen Liu indicated no relevant financial relationships.
April Whitaker indicated no relevant financial relationships.
Ross Taliano indicated no relevant financial relationships.
Zilla Hussain indicated no relevant financial relationships.
Daniel Marino, MD, MBA, Breton Roussel, MD, Yuchen Liu, MD, April Whitaker, MD, Ross Taliano, MD, Zilla Hussain, MD. P1549 - Life-Threatening Gastrointestinal Hemorrhage as a Complication of a Cholecystogastric Fistula, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.