Importance of Spontaneous Choledochoduodenal Fistulas Detected During ERCP Procedure

Abstract

Choledochoduodenal fistula (CDF) is an abnormal passage between the choledochus and duodenum. The most common causes of CDF are cholelithiasis, duodenal ulcer, and tumors. There are mainly two types of fistulas depending on the location. Type 1 is usually present on the longitudinal fold just close to the papilla. Type 2 is present at the duodenal mucosa adjacent to the longitudinal fold and probably caused by larger stones, duodenal ulcer penetration, impacted cystic duct stones, and as a complication of laparoscopic cholecystectomy. In this study, we investigate the characteristics of our patients those were diagnosed with CDF. This is a descriptive study. We retrospectively obtained the data of 21 patients with spontaneous CDF out of 2430 endoscopic retrograde cholangiopancreaticography (ERCP) patients between 2000 and 2014. We analyzed the laboratory results, demographic and etiological features, major clinical presentations, diagnostic methods, and treatment modalities of the patients. The mean age of the 21 patients was 66.6 ± 2.2 years and a female to male ratio was 12:9. In ten patients, interventional procedures were performed via fistulotomy, not through the papilla. The eventual diagnosis was tumor in five patients and stone or sludge in bile ducts in 14 patients. In the remaining two patients, no reason was found as a cause of CDF. Whipple operation was performed in one patient and stents were placed in three patients for malignacy. Among the 14 patients with sludge or stone in bile ducts, ERCP has been therapeutic in ten. One of the remaining patients has been operated for proximal fistula and underwent choledochus exploration and repair of fistula over a T-tube. In the second patient, stone extraction and T-tube drainage were performed. In patients who had bile duct obstruction and got over of jaundice afterwards, one of the most important reasons of this recovery is the development of spontaneous choledochoduodenal fistula. Even if it is very rare, malignancy can be observed in this area. Therefore, it is extremely important to evaluate the papillary area with ERCP and to conduct biopsy; this will make early diagnosis possible in many patients. In these patients, ERCP can both be diagnostic and therapeutic.

Keywords: Choledochoduodenal; ERCP; Fistula; Papillotomy; Stent.

Fig. 1

ERCP showing the CDF orifice above the papilla

Fig. 2

Cannulation of the fistula orifice

Fig. 3

A plastic stent placed through CDF via ERCP

Fig. 4

An SEMS placed through CDF via ERCP