A Rare Occurrence of Cholecystogastric Fistula Mimicking Perforated
Peptic Ulcer Symptoms
Running title: Cholecystogastric fistula misdiagnosis
Authors: Hossein Torabi1, Kasra
Shirini2*, Dorsa Shirini3, Rona
Ghaffari1
- Department of General Surgery, Poursina Medical and Educational
Center, Guilan University of Medical Sciences, Rasht, IRN
- Department of General Surgery, Iran University of Medical Science,
Tehran, IRN
- Cardiovascular Research Center, Shahid Beheshti University of Medical
Sciences, Tehran, IRN
- Department of General Surgery, Poursina Medical and Educational
Center, Guilan University of Medical Sciences, Rasht, IRN
Number of Figures and Tables: 4 Figures and 0 Table
*Correspondence author:
Kasra Shirini, MD
Department of General Surgery, Iran university of medical science,
Tehran, Iran
Telephone: +989112481500 Fax number: +982166879611
E-mail:
KasraShirini21@gmail.com
ORCID-ID: https://orcid.org/0000-0003-4104-7633
Acknowledgment: None
Disclosure of conflicts of interest: The authors certify that there is
no conflict of interest with any financial organization regarding the
material discussed in the manuscript. The patient has consented to the
submission of the case report for submission to the journal.
Funding: The authors report no involvement in the research by the
sponsor that could have influenced the outcome of this work.
Authors’ contributions: All authors contributed equally to the
manuscript and read and approved the final version of the manuscript.
Patient’s contest: Written informed consent was obtained from the
patient to publish this report in accordance with the journal’s patient
consent policy.
Key Clinical message: Cholecystogastric fistula is one of the rarest and
most life-threatening complications of gallbladder stone disease. This
disease can mimic other diseases such as perforated peptic ulcers and is
too hard to be diagnosed preoperatively. It should be considered a
significant differential diagnosis in patients with abdominal pain and
cholecystitis symptoms.
Abstract:
Cholecystogastric fistula is one of the rarest and most life-threatening
complications of gallbladder stone disease. This disease can mimic other
diseases such as perforated peptic ulcers and is too hard to be
diagnosed preoperatively. This article presents a patient with
cholecystogastric fistula presentation as a peptic ulcer disease. This
article presents a 58-year-old man with the presentation of abdominal
pain and acute cholecystitis symptoms mimicking perforated peptic ulcer
during hospitalization. Clinical examination and imaging confirmed the
diagnosis of peptic ulcer disease. Laparotomy revealed that the disease
was a simultaneous gallbladder stone disease, which led to acute
cholecystitis and following cholecystogastric fistula. Cholecystogastric
fistula should be considered a significant differential diagnosis in
patients with abdominal pain and cholecystitis symptoms.
Keywords: Cholecystogastric fistula, Cholecystoenteric fistula,
Cholecystitis, Bile duct, Abdominal pain.
Introduction:
The prevalence of gallstones worldwide varies between 5 % to 25
% [1].
In Iran, the prevalence of this disease is approximately 1.1 % in male
patients and 12.8% in female patients between 50 and 60 years old,
which is highly increased by
aging [2].
The gallbladder can cause different problems and one of the most common
and important problems, which can lead to surgical intervention, is
acute
cholecystitis [3].
On the other hand, this disease can cause rare but health hazards such
as cholecystoenteric fistula, an abnormal connection between the
gallbladder and
stomach [1].
because of its very nonspecific symptoms that can be confused with other
conditions such as a perforated peptic ulcer or just single acute
cholecystitis, it is often diagnosed during surgery
(92.1%) [4].
Studies have shown that the prevalence of fistula between gallbladder
and other organs depends on its location, and the prevalence of
cholecystogastric fistula is less than others, approximately just
2% [1,5].
The main way to treat and eradicate cholecystogastric fistula, which is
a life-threatening problem, is surgery. But choosing the surgical
methods such as open or laparoscopy or endoscopic surgery depends on
various factors such as the patient’s condition and possible diagnosis
that the surgical team considers for the
patient [1,6,7].
In this study, a 58-year-old man was presented with acute cholecystitis
and cholecystogastric fistula symptoms with a clinical presentation
mimicking acute cholecystitis and perforated peptic ulcer.
Case Report:
A 58-year-old male presented to the surgical Department of Poursina
Hospital Medical Center, in Rasht, Iran, in November 2021, with a
four-day history of severe generalized abdominal pain with a
predominance of the epigastric and right upper quadrant (RUQ) area of
the abdomen with the radiation to the patient’s back and right shoulder.
The pain started suddenly and increased dramatically. The patient
claimed that a day before coming to the hospital, he had vomited three
or four times, containing food, and he claimed that there was no blood;
the pain increased by feeding, but it had nothing to do with defecation
and gas-passing. The patient claimed that he did not have any defecation
since two days before he came to the hospital, but he said that he had
gas-passing. He also mentioned that he had an intermittent low-grade
fever and the highest degree recorded by him was 38.5 degrees Celsius.
It did not decrease after using medication such as acetaminophen tablet
500 mg. More investigation revealed that the patient had diabetes three
years ago, and metformin was prescribed. However, he did not take any
medicine and arbitrarily stopped taking them six months after starting
medication. The patient had a low-grade fever (38 degrees Celsius) at
the time of admission, but other vital signs were normal. On abdominal
examination, the patient had moderate generalized tenderness with a
predominance of RUQ and epigastric area, but distention and gardening
were not detected during the abdominal examination. He was asked to do
an upright chest X-ray and an upright abdominal X-ray due to suspicion
of peritonitis. He also was asked to do abdominal ultrasonography due to
suspicion of acute cholecystitis. The ultrasonography reports
represented the gallbladder with dimensions of 83x35 mm and increased
wall thickness is about 5 mm, and the existence of 2 gallstones
measuring 24 mm and 10 mm. On the other hand, in the patient’s chest and
abdominal X-ray, a suspicious air level was seen below the right side of
the diaphragm, as can be seen in Figures 1 and 2.
The blood test analyzed presented a high level of erythrocyte
sedimentation rate (ESR)=93 (usually should be under 15 in males),
C-reactive protein (CRP) = 200 (usually should be under 5 in adults),
and leukocytosis (white blood cells [WBC] = 15700 g/dL with a
neutrophilia ratio of 68%), Amylase = 588 (usually should be under 95
in adults), Fecal occult blood test were positive, Lipase =20 (usually
should be under 60 in adults), and hemoglobin (Hb) = 9.8 g/dL ( usually
should be between 12 -14 in adult males). According to the patient’s
clinical presentation and our investigations, such as ultrasonography,
chest and abdominal X-ray, and blood test results analysis, two main
diagnoses were made: suspicion of peritonitis caused by perforated
peptic ulcer and acute cholecystitis. Due to the patient’s deteriorating
condition, such as progress to severe and generalized abdominal
tenderness and RUQ and epigastric rebound tenderness and sudden
metabolic acidosis appeared in patients atrial blood gas (ABG) result,
surgeons suspecting peritonitis caused by perforated peptic ulcer
decided to perform an emergency laparotomy, instead of asking the
patient for abdominal computed tomography (CT) scan or preparing an
endoscopy procedure. Perforated peptic ulcers followed by peritonitis
can be life-threatening, so it should be considered the first and most
important diagnosis to save the patient’s life. A midline incision was
made for the patient’s abdomen. The gallbladder was found to be severely
inflamed. A small amount of debridement and free fluid was seen around
the gallbladder near the stomach. After resection of the adhesion
between the infundibulum part of the gallbladder and the stomach, a
perforated wound measuring 1x1 cm was seen in the prepyloric area of the
stomach exactly in the posterior part of the gallbladder, as can be seen
in Figure 3. A cholecystogastric fistula was also seen between the
gallbladder and the stomach wall, from which gastric secretions exuded.
Due to two large gallstones in the gallbladder, the patient underwent
cholecystectomy. The gallbladder after resection can be seen in
Figure 4. The wound in the prepyloric area of the stomach wall was
repaired by wedge resection, and a biopsy was prepared and sent to the
laboratory for more investigation. The abdominal cavity was washed with
normal saline serum, and a drain was inserted for the patient. The
patient’s stomach was partially closed. On a postoperative day one, his
vital signs were within normal limits. Due to the infection in the
abdominal cavity, the patient was treated with the injected
metronidazole and ceftriaxone during hospitalization. The patient’s skin
was finally wholly closed with a delay of one week and relative
treatments of the patient’s infection. After the second surgery on
postoperative day 5, he was discharged. Eventually, the postoperative
histopathology report was unrevealing.
Discussion:
This article presented an acute cholecystitis case with
cholecystogastric fistula, which occurred in a 58-year-old man,
mimicking perforated peptic ulcer. Gallbladder stone disease is seen
worldwide, including in
Iran [2].
One of the most common reasons that can lead to cholecystitis is
gallbladder stone. Cholecystogastric fistula is a rare and
health-threatening complication of
cholecystitis [1,8].
The probability of fistula occurring between the gallbladder and
different parts of the gastrointestinal tract is different and depends
on their location. The most common of them is cholecystoduodenal fistula
with the prevalence of 77%-90%, and the rarest of them is
cholecystogastric fistula with the probability of
2% [5,8,9].
Although, because of development occurred in computed tomography (CT)
scan technology and endoscopic techniques and technology, it is much
easier for surgeons to diagnosis cholecystoenteric fistula such as
cholecystogastric fistula preoperatively, it is still too hard to
diagnose this disease preoperatively because it does not have any
specific symptoms compared with
cholecystitis [7].
The main way to treat this disease is surgery. However, there are
different surgical methods, such as open surgery, laparoscopic surgery,
and endoscopic surgery; the consideration of the most appropriate method
is based on the patient’s condition and surgical team decision and
consideration [1,7,10].
In this case, the patient was initially scheduled to undergo an
abdominal CT scan after the investigations. However, due to the
patient’s clinical condition, such as metabolic acidosis, which appeared
suddenly in the patient’s blood test results and was not in the
patient’s previous test, and the rebound tenderness that became
generalized and intensified and expanded, the patient underwent
laparotomy. Various studies have been performed on the types of
cholecystoenteric fistula, its diagnosis, and its treatment
methods [1,6,7,8].
However, given the rarity of this disease, and the fact that it can be
life-threatening and that it can be confused with other dangerous
diseases such as perforated peptic ulcer, which are also
life-threatening, the diagnosis and choosing the right and the most
appropriate treatment method, which is based on patient’s clinical
condition and clinical findings, is crucial.
Conclusion:
Cholecystogastric fistula is a type of cholecystoenteric fistula that
occurs very rarely and is one of the most important and life-threatening
complications of gallbladder stone disease. Unfortunately, it is too
hard to diagnosis this disease preoperatively, and it can mimic other
health hazard diseases such as a perforated peptic ulcer. Therefore, it
is crucial to consider this disease in patients who presented to the
hospital with abdominal pain and symptoms of cholecystitis to diagnose
it and select the most appropriate treatment methods.
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Figures Caption:
Figure1: Upright chest X-ray: The green arrow shows the suspicious
free air level
Figure2: Upright Abdominal X-ray: The green arrow shows the suspicious
free air level
Figure3: Perforated peptic ulcer: The green arrow shows the
perforation which is located in the prepyloric area of the stomach
Figure4: The gallbladder and its gallstones after resection