Spontaneous cutaneous biliary fistula: a rare complication of cholangiocarcinoma

A rare case of intrahepatic-cutaneous biliary fistula resulted from obstruction of the biliary tree by cholangiocarcinoma in the hilar area. The diagnosis was made clinically by the presence of a constant pus discharge through the fistula opening and confirmed by sonogram, computed tomogram (CT), and surgery. To our knowledge, there have been no previous reports of such a fistula as the presenting symptom of cholangiocarcinoma.     

Spontaneous external biliary fistula arising from an intrahepatic duct

A spontaneous external biliary fistula is most commonly a cholecystocutaneous fistula secondary to acute cholecystitis. A fistula arising from an intrahepatic duct is extremely rare. An 87-year-old man presented with swelling of the epigastric region and right upper quadrant abdomen. He had a history of cholecystectomy and endoscopic sphincterotomy. After antibiotic treatment and surgical opening of both lesions, abdominal computed tomography demonstrated a soft tissue mass cephalad to the umbilicus. We excised the mass, and found it to be associated with a fistula through the linea alba. Fistulography showed an abscess cavity communicating with the intrahepatic duct in segment III. Histopathological examination of the mass showed an abscess without malignancy. The fistula closed spontaneously without laparotomy. In this case, the underlying pathology was considered to be associated with a subcapsular hepatic cyst in segment III.     

Pancreaticoportal fistula: a rare complication of chronic pancreatitis

We report a patient with chronic alcoholic calcifying pancreatitis in whom a pancreaticoportal fistula was demonstrated by endoscopic retrograde pancreatography. No complications could be ascribed to this fistula except for thrombosis of the portal, splenic, and superior mesenteric veins. An expectant conservative management was adopted. A short review of the six other cases reported in the literature is presented.     

Pancreatico-pericardial fistula: a rare complication of chronic pancreatitis.

A 16-year-old boy presented with pericardial effusion, bilateral pleural effusion and mediastinal fluid collection. CT scan of abdomen revealed pancreatic calcification and a fistulous tract from a pseudocyst going along the inferior vena cava wall up to the pericardial cavity. After initial pericardiocentesis and pleurocentesis, lateral pancreatico-jejunostomy with Roux-en-Y loop was performed. The patient is well at 6 months follow up.     

Aorto-cutaneous fistula: a rare complication of aortic surgery.

Two cases of false aneurysm of the ascending aorta which presented with discharge of arterial blood from a sternal wound are discussed. The first presented 8 years after aortic valve surgery and was diagnosed by contrast enhanced computerised tomography of the thorax. The second presented 6 months following repair of an aortic dissection and the diagnosis was confirmed by thoracic magnetic resonance imaging. The diagnosis and surgical management of these cases are reviewed.     

Aorto-right artrial fistula: a rare complication of aortic dissection

We describe the successful surgical repair of an acute aortic dissection that had caused an aorto-right atrial fistula in a 67-year-old man. The patient was admitted to the hospital on an emergency basis because of severe heart failure. The diagnosis of acute aortic dissection with rupture into the right atrium was confirmed by use of intraoperative transesophageal echocardiography, although rupture of a sinus of Valsalva aneurysm into the right atrium had been suggested initially by 2-dimensional and Doppler transthoracic echocardiography. At surgery, we found the patient to have aortic arch dissection with complete separation of the right coronary artery from the sinus of Valsalva and a false lumen that had ruptured into the right atrium. The aortic arch was repaired directly. The ascending aorta was successfully replaced with a composite graft. Aortic dissection with rupture into the right atrium is extremely rare and leads to death rapidly. As shown in this case, such a condition might be mistaken for an aneurysmal rupture of the sinus of Valsalva, with use of transthoracic echocardiography alone. Transesophageal echocardiography is a useful noninvasive method to further define or confirm the diagnosis. Early surgical intervention is necessary in patients with this condition to prevent profound shock and end-organ failure.     

Spontaneous colonic perforation: a rare complication of collagenous colitis

Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and unique histopathologic features. Spontaneous colonic perforation in the setting of collagenous colitis is a highly unusual complication, with only three cases reported in the literature to date. We present a fourth case and propose a potential pathologic mechanism for acute colonic perforation in this patient population.     

A case of choledochoduodenal fistula as a delayed complication after biliary metallic stent placement in distal cholangiocarcinoma]

Biliary drainage in patients with malignant biliary obstruction relieves jaundice and prevents the development of cholangitis or hepatic failure from biliary obstruction. Therefore, this may result in better quality of life along with survival prolongation. Biliary stent placement is an effective and safe measure for biliary decompression and is preferred than bypass surgery in high risk patients. Entero-biliary perforation-communication is one of the rare complications of biliary stent. We herein report a case of duodeno-biliary perforation-communication in patient with distal cholangiocarcinoma who presented with duodenal ulcer and obstruction, occurring 4 years later from the metallic biliary stent insertion. Patient was managed with a pyloric metal stent and conservative care.     

Pneumopericardium as a rare complication after esophagopericardial fistula

Pneumopericardium is a rare clinical entity which is often complicated by trauma. Pneumoperdicardium resulting after esophagopericardial fistula is much rarer. We present a case of pneumopericardium as the complication of esophagopericardial fistula in a 53‐year‐old man. After undergoing radiotherapy for 26 times, the patient got a fever and an unspecified thoracic pain. Echocardiography showed the rectilinear echoes in the pericardium. Chest computed tomography revealed pneumopericardium, pericardial effusion, recurrence of lung cancer, and pneumonia in right lower and left lung.     

Spontaneous gastrojejunal fistula is a complication of gastric ulcer

Spontaneous gastrojejunal fistula formation is an extremely rare complication of gastric ulcer disease. We report a 77-year old woman who presented with diffuse abdominal pain, weight loss, malaise, nausea, and occasional dark stools. Laboratory tests showed extreme hyposideremic anemia with inflammatory syndrome. In addition, biochemical parameters of malnourishment were presented. Upper endoscopy revealed the patent esophagus along the full length without any pathological changes. Large and deep ulceration with perforation in the small intestine was detected in the posterior gastric wall. The small intestine loop was reached by endoscope through spontaneously developed gastrojejunal fistula. Polytopic biopsies of described ulcerative change were carried out. Histopathologically reepithelialized ulcerous zone was seen in the gastric mucosa. Also, gastrojejunal fistula was visualized after wide opening of hepatogastric and gastrocolic ligament. Jejunal loop 25 cm from ligament of Treitz was attached to mesocolon and posterior gastric wall because of ulcer penetration. Postoperative course was uneventful, Per oral intake started on the 4^th postoperative day, and the patient was discharged on the 8^th postoperative day. In summary, this case indicates that persistent symptoms of peptic ulcer disease associated with nutritional disturbances may be caused by gastrojejunal fistula.     

Biliopleural fistula： A rare complication of percutaneous transhepatic gallbladder drainage

A 79-year-old previously healthy man presented with acute acalculous cholecystitis with obstruction of the biliary tract. He was successfully treated with antibiotics and percutaneous transhepatic gallbladder drainage, but returned to the hospital two days after discharge with a rare complication of this technique, biliopleural fistula. A thoracostomy tube was inserted to drain the pleural effusion, and the patient’s previous antibiotics reinstated. After two weeks of drainage and antibiotics, the fistula healed spontaneously without the need for further intervention.     

Cholelithiasis and cholecysto-colonic fistula: a rare form of biliary ileus

A case is described of cholecystocolonic fistula with colonic obstruction by a gallstone, an infrequent form of presentation of the bilioenteric fistulas. We briefly review the etiopathogenesis, symptomatology, diagnosis and therapy of this condition.