An Unusual Case of Choledochoduodenal Fistula Secondary to Peptic Ulcer Presenting With Cholangitis and Pneumobilia

Abstract

Choledochodoudenal fistula is an uncommon bilio-enteric fistula with clinical presentation ranging from having no symptoms to frank cholangitis. The causes of choledochodoudenal fistula are multiple, with bile duct stones being the most common. Duodenal ulcer is rarely the source of choledochodoudenal fistula. Clinical diagnosis defies acumen, and high-quality imaging including endoscopic or radiologic imaging is required for confirmation. Management of choledochodoudenal fistula is not standardized and remains challenging. We report an unusual case of a choledochodoudenal fistula caused by a duodenal ulcer that presented with pneumobilia and cholangitis. Treatment demanded medical, endoscopic, radiologic, and, ultimately, surgical intervention.

Keywords: cholangitis; choledochodoudenal fistula; duodenal ulcer; endoscopic retrograde cholangiopancreatography; percutaneous transhepatic cholangiography.

Figure 1. Radiograph showing the passage of the contrast into the biliary tract during injecting the contrast through the fistula.

Figure 2. (A) Cholangiogram showing contrast injection by the intervention radiologist through the right intrahepatic ducts, (B) with the passage of the contrast through the common bile duct fistula into the duodenal bulb.

Figure 3. Endoscopic picture of the duodenal bulb, (A) showing the fistula orifice located in the duodenal bulb, penetrating the wall of the bile duct. (B) The biliary plastic stent is visible inside the bile duct.