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

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

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

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

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

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

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

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

15. Shaimaa Elkholy, M.D. Cairo University

16. 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

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

18. 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

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

20. Shaimaa Elkholy, M.D. Cairo University

21. Shaimaa Elkholy, M.D. Cairo University

22. Shaimaa Elkholy, M.D. Cairo University

23. Shaimaa Elkholy, M.D. Cairo University

24. 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

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