Title: who presented with a right hypochondrium discharge

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Last updated: August 25, 2019

Title: Spontaneous Cholecystocutaneous fistula .

….. Abstract: One of the most unusual complications in gall bladder disease  is spontaneous cholecystocutaneous fistula, which has only been reported a few times in the literature.Cases of cholecystocutaneous fistulas are now a rare occurrence as a result of rapid diagnosis and treatment.

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 Make one sentence from above two sentence  We report the case of a 67 year old man who presented with a right hypochondrium discharge sinus. Confirmation of cholecystocutaneous fistula was made  by computed tomography with contrast media, followed by MRCP . This confirmed the presence of a fistulous pathway between the gallbladder and the skin.  The patient underwent subtotal cholecystectomy surgery and open laparotomy with en block aponeurotic muscle, skin and fistula orifice excision.   IntroductionSpontaneous cholecystocutaneous fistula (SCF) is an exceptionally uncommon complication of gall bladder disease. Thelissus first described the condition in in 1670, and since 2007 there have only been 28 cases published.1  Due to availability of increasingly sophisticated medical imagining techniques and higher standards of public health in general, the incidence of such cases is expected to have markedly declined.

Wider acceptance of laparoscopic cholecystectomy has brought about a revolution in management of the cholelithiasis. Nonetheless, occasionally in neglected, compromised, elderly, cholelithiasis patients with long standing disease, such rare complication can occur. We report a case of 67 year old patient who presented with a discharging sinus in right upper quadrant/ hypochondrium and suspected SCF.Case:Initial presentation and history:We present a case of 67-year-old man presenting to the emergency department of our hospital with chief complaints of pain and swelling over the right upper abdomen for 30 days, and discharge from right upper abdomen for 25 days. There was no history of fever. The patient had  cholelithiasis for 10 years . He had episodes of abdomen pain 4 years earlier which subsided after taking medication. The patient had past history of head injury, craniotomy and convulsions 20 years earlier and he was on antiepileptics and an(on) antihypertensive.

He also had ischemic heart disease and had had percutaneous transluminal coronary angioplasty performed in 2012.) Physical examination:He presented with pallor and was severely hypertensive (180/100mmHg).On per abdomen examination approximately  10cm x 8cm soft to firm mass in right hypochondrium , mild tenderness,  and sinus opening with serous like discharge. Surrounding skin was indurated but non-tender and local temperature was not raised.

 Laboratory examination and radiological study:Blood test revealed haemoglobin 7mg/dl, white blood cell count was 18,000, C-Reactive protein was 80mg/L, International normalization ratio (‘INR’) was 4 , Liver Function Test (‘LFT’) unremarkable except raised Alkaline Phosphatase (‘ALP’)  Contrast Enhanced Computed Tomography revealed   a  thick walled gall bladder and thick walled enhancing fistulous tract extending from gall bladder to anetrior  upper  abdominal wall.Magnetic resonance imagining (‘MRCP’)  revealed a track running from base of the gall bladder to  anetrior  upper  abdominal wall and  not communicating with common bile duct, duodenum colon stomach and confirmed with gadolinium sinogram. And a caculus was noted as well defined defect in gall bladder.  Also, 2D Echo showed 45% Ejection Fraction with Grade 3 Left Ventricle dysfunction  Treatment and outcome: Patient was started on broad spectrum intravenous antibiotics and anti-hypertensive.

 Fresh-frozen plasma transfusion (FFP) transfusion done for deranged INR. Blood transfusion done for anaemia. After initial stabilization patien  mmmmmmt planned for surgery on the second  day after diagnosis.

The patient underwent elective subtotal cholecystectomy performed through subcostal incision and single large gall bladder stone (6cm) retrieved, en-block aponeurotic muscle skin and fistula orifice excision, with drain placement. During surgery common bile duct, colon, jejunum, stomach inspected carefully for any communication. In post-operative period patient was shifted to Intensive Care Unit (ICU). On post operative day 2 (POD2), the patient had delirium but serum electrolytes were normal.

So, in view of hepatic encephalopathy serum ammonia levels were done, that were raised (65µmol/L). Syrup lactulose was given. On POD4, the patient become stable and shifted to ward and started orally. Drain removed on POD6. and patient discharged on POD8.

Histopathology reports confirmed the Acute on chronic cholecystitis, without any evidence of malignancy.  Discusssion A. The pathophysiology of the condition involves increased pressure in the gallbladder, secondary to cystic duct obstruction, either caused by a calculus or neoplasia.

 2 B. Predisposing factors are cholelithiasis, infections, malignancy, diabetes, atherosclerosis, prolonged high dose steroids 3 associated disease like polyarteritis nodusa. 4 C. Fundus most distant from cystic artery and physiologically least vascularised therefore most susceptible to ischemia hence is the most common site of perforation .5,6  D. The increase in intraluminal pressure compromises the venous and lymphatic drainage of gallbladder resulting in necrosis and finally gallbladder perforation. 7 E. Spontaneous biliary fistula may be internal or external, most being internal.

8 F. Internal fistula connections are duodenum 77%, colon 15%, stomach, jejunum, CBD,  9 G. Generally, fistula or abscess present in right upper quadrant, although other locations such as epigastrium, umbilical, right groin, even the gluteal region, right breast have also been described. 3,10,11. H. Rare cases of biliary fistulas joined to other areas like the renal pelvis, uterus, vagina, ovary, urinary bladder, hepatic artery, portal vein, pericardium, and bronchial tree have also been reported .12,13, 14  I.

 Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess15 J. In 1934, Niemeier proposed a classification of gallbladder perforation: Type  I – acute free perforation into peritoneal cavity, without protective adhesions; Type II – subacute perforation with pericholecystic abscess; and Type III – chronic perforation with cholecystoenteric fistula. 3,16 K. A fourth type is suggested by Andersen et al.

type IV: cholecystobiliary fistula formation 17 .  L. Roslyn et al 18 reported in their study that type 1 and type 2 gallbladder perforations are mostly seen in young patients (< 50 years), and type 3 is seen in elderly with long history of stone disease.  M. The state preceding spontaneous rupture has been termed "empyema necessitatis" by Nayman.The term essentially describes a "burrowing abscess" of the abdominal wall as a result of gallbladder inflammation. 19  N.  CT scan finding can be divided into primary gallbladder changes, pericholecystic changes and findings in extra-gallbladder organs.

Primary gallbladder changes include wall thickening, wall enhancement, wall defect, intramural abscess, intramural gas, mural haemorrhage, presence of gallstones, bile duct stones or cystic duct stones, intraluminal membrane and intraluminal gas. Pericholecystic changes include pericholecystic fat stranding, pericholecystic fluid collection, abscess or biloma formation and presence of extra-luminal stones. Findings in organs other than the gallbladder consist of pericholecystic liver enhancement, liver abscess, portal vein thrombosis, lymphadenopathy, reactive mural thickening of adjacent hollow organs (hepatic flexure of colon and duodenum), intra-peritoneal free air,  ascites  and Mirizzi syndrome. 3O. Surgical management approach for SCF 1 Two stage surgical treatment for septic patient with poor clinical outcome..External drainage of the abscess and antibiotics were used for enabling biliary drainage and sepsis control then cholecystectomy and fistula excision 2 Single stage procedure like the one we performed is considered to be the treatment of choice 3 Single stage laparoscopic recently performed by Kumar.

1,20, Malik et al describe an approach that involves the laparoscopic removal of the gallbladder and dissection but not excision of the fistula from the abdominal wall 21. P. Common bile duct obstruction, caused by a stone can be treated by endoscopical extraction of stones first, and then cholecystectomy with excision of the fistula. Patients with ampullary stone impaction, biliary pancreatitis and multiple comorbidities are considered good candidates for preoperative endoscopic therapy. If clearance is not possible because of multiple stones, intrahepatic stones, impacted stones, duodenal diverticula, or biliary stricture, this information is known before surgery. Endoscopic stone extraction is well tolerated in most patients. Mathonnet et al.

suggested laparoscopic cholecystectomy as a feasible procedure, but it has a high conversion rate 22. Q. In most series, subacute perforation with pericholecystic abscess is the most common type as a complication of acute cholecystitis.

“23 R. In one series there was a 40% mortality rate associated with type 1 free perforation and a 4% mortality rate for type 2.23.S. Because clinical signs and symptoms are frequently nonspecific and indistinguishable from those of uncomplicated acute cholecystitis, radiologic studies play a vital role, and it is generally agreed that CT is superior to USG  for this purpose. 15 T. Prompt surgical intervention is warranted to decrease morbidity and mortality in patients with gallbladder perforation. inspection in intraoperatively of cbd and other viscera.

 And meticulus post operative monitoring carefull in elderly patient with significant co-morbidity     These findings illustrate the pathologic process that leads to formation of a      

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