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Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 43-45

Perforated acute cholecystitis complicated by a fistula to the appendix

Meritus Surgical Specialists, Hagerstown, MD, USA

Correspondence Address:
Hugo Bonatti
Meritus Surgical Specialists, 11110 Medical Campus Road, Suite 147, Hagerstown, MD 21742
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wjsi.wjsi_4_22

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Fistulas between the gallbladder (GB) and intestinal tract are rare but require surgical repair. The most commonly involved alimentary tract segments are the duodenum and the hepatic colon flexure. An 80-year-old obese male with multiple comorbid conditions presented with acute right upper quadrant pain, weakness, and signs of sepsis; computed tomography (CT) scan showed a perihepatic phlegmon and pneumobilia suspicious for contained GB perforation. He was not a surgical candidate at this time; antibiotics were started and a percutaneous cholecystostomy tube was placed. Magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis and he underwent endoscopic retrograde cholangiopancreatography revealing GB perforation and tracking of contrast toward the right lower quadrant; stone extraction was done and a biliary stent was placed. After 2 months of rehabilitation and clinical improvement, he underwent laparoscopic interval cholecystectomy. The appendix was fused with the GB creating a cholecystoappendiceal fistula. The appendix was stapled at the cecal base. Thereafter, the cholecystectomy was done. The GB fundus was fused to the hepatic duct, and during dissection, an anterior wall injury to the hepatic duct occurred, which was successfully managed by laparoscopic T-tube insertion. The patient recovered well and removed the T-tube himself after 4 weeks. An MRCP showed no evidence of a leak or stenosis. To the best of our knowledge, this is the first reported case of a cholecystoappendiceal fistula, which explains the pneumobilia on the initial CT scan. In a retrospective study, the cholangiogram showed the pathology but was not recognized. Combined laparoscopic appendectomy and cholecystectomy was done.

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