Choledochoduodenal fistula

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Fig. 15. Choledochoduodenal fistula

Presentation transcript:

Choledochoduodenal fistula Prof. Sherif Mogawer Shaimaa Elkholy Cairo University, Egypt Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University Case presentation A 55 years old male patient presenting with acute onset of epigasrtic pain associated with vomiting ,rigors, chills and fever reaching up to 39 c The patient had history of melena 5 years ago for which he was admitted to the hospital UGI endoscopy was done to him showing peptic ulcer disease Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University Case presentation Case presentation The patient was discharged on PPI that was prescribed to him and he was instructed to quit smoking and stop NSAIDs but the patient was not compliant On examination the patient had epigastric and right hypochondrial tenderness Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University Case presentation Case presentation Laboratory tests showed: leucocytosis (13,500) with shift to the left Abdominal ultrasound showed microlithiasis of the gallbladder and presence of air in the common bile duct (pneumobilia) Shaimaa Elkholy, M.D. Cairo University

We proceeded for UGI endoscopy video attached Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Incidence: It’s a very rare condition Accounts for about 5 % of all bilio-enteric fistulas Bilio-enteric fistulas: Cholecystoduodenal most common Cholecyscolonic Cholecystogastric Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CFD) Its rarity referred to the fact that the commonest site of duodenal ulcer is about 4 cm from the pyloric ring and CBD is about 7 cm from the pylorus Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Incidence: Male : female ratio is 3:1 5th- 6th decade It has 2 types: Proximal CDFs “ posterior bulb wall” Distal CDFs “periampullary” Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Aetiology of the spontaneous CDFs: Penetrating duodenal ulcer 80 % (PCDFs) Choledocholithiasis (DCDFs) Malignancies Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Presentation : Asymptomatic “most common” Ascending cholangitis Obstructive jaundice UGIB “rare” Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Diagnosis : Imaging X-RAY Pneumobilia Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Diagnosis : Imaging U/S Pneumobilia Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Diagnosis : Imaging C.T. Pneumobilia Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Diagnosis : Endoscopy UGI ERCP Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University choledochoduodenal fistula and Cholangiogram was demonstrated by introducing contrast medium into the fistula Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Management : Debate of MEDICAL versus SURGICAL Medical: Asymptomatic or high risk Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Management : Surgical: Used to be the main line “prophylactic” Reserved for failed medical, bleeding & biliary obstruction Laparoscopic surgery Vagotomy and gasterojejonostomy Shaimaa Elkholy, M.D. Cairo University

Choledochoduodenal fistula (CDF) Management : Other modalities Endoscopic closure over -the scope -clips Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University Take home message CDFs rare sequel for long standing duodenal ulcer CDFs should be bared in mind when the patient starts to develop unusual symptoms e.g. jaundice , cholangitis Adequate biliary drainage should be ensured before management Endoscopic closure using over the scope clip may be the modality of choice Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University Thank you Thank you Shaimaa el kholy Shaimaa Elkholy, M.D. Cairo University