Cholecystocutaneous Fistula - Causes, Symptoms, Diagnosis, and Treatment

Introduction

The gallbladder is a small organ in the human body that stores bile (a digestive fluid) and transfers the bile into the small intestine for digestion. It is present just below the liver on the upper right side of the abdomen. Sometimes, the gallbladder becomes infected or inflamed, which causes gallbladder-related diseases such as cholecystitis. If the gallbladder tract is blocked due to the hardening of the bile, then it causes gallstones.

A cholecystocutaneous fistula is a rare and abnormal connection between the gallbladder and the skin. It occurs when a gallbladder-related disease is left untreated. The severity and occurrence of this condition depend on various factors such as the patient’s age, medical history, presence or absence of an abscess in the abdomen wall, clinical presentation, etc. Unfortunately, there is no standard line of treatment for this condition, and it may vary from patient to patient. Elective cholecystectomy is the most commonly recommended surgical treatment.

What Is Cholecystocutaneous Fistula?

It is an external biliary fistula that connects the gallbladder with the skin. It is a rare condition that occurs due to complications of a disease or surgical intervention.

What Is a Biliary Fistula?

A biliary fistula connects the biliary tract with other organs. It occurs as a rare complication of gallstone. There are two types of biliary fistula:

• Internal Biliary Fistula - Connects the gallbladder with the gastrointestinal tract.

• External Biliary Fistula - Connects the gallbladder with the skin.

What Is the Location of Cholecystocutaneous Fistula?

The most common opening of the fistula is the right upper quadrant of the abdomen. Sometimes, the opening is present in the left costal margin, right iliac fossa, or right gluteal region.

What Causes Cholecystocutaneous Fistula?

The causes of cholecystocutaneous fistula are:

• A rare complication of neglected or untreated calculous cholecystitis is inflammation of the gallbladder caused by stones and blockage.

• Carcinoma or cancer of the gallbladder.

• Spontaneously after cholelithiasis or gallstones - hard deposits of digestive fluid present in the gallbladder.

• Escherichia coli is the most common bacteria present in cholecystocutaneous fistula that causes infection and abscess.

What Is the Pathophysiology of Cholecystocutaneous Fistula?

The gallbladder is a small organ present just below the liver on the upper right side of the abdomen. It holds the digestive fluid called bile that flows into the small intestine for digestion. Gallstones are hard deposits of bile. When a gallstone is formed, it obstructs the gallbladder and biliary flow. This obstruction leads to increased pressure in the gallbladder resulting in compromised blood supply in the gallbladder and lymphatic drainage. This leads to the necrosis of the gallbladder. An opening or perforation of the gallbladder also occurs in the later stage, leading to abscess formation. This abscess drains into the peritoneal cavity - space within the abdomen, liver, intestines, etc. The abscess further develops a fistula externally and connects the abdominal wall where there is minimum resistance.

What Are the Symptoms of Cholecystocutaneous Fistula?

• Presence of sinus through which the bile is discharged.

• Pain and swelling in the right upper quadrant of the abdomen.

• Fever.

• Nausea and vomiting.

• Presence of external opening of the fistula.

How to Diagnose the Cholecystocutaneous Fistula?

1. Medical History of Patient: Usually, the patient will give a history of chronic biliary tract disease. Sometimes, the patient may give a history of draining or release of a gallstone from the fistula.

2. Physical Examination: The fistula site that is in the upper right region of the abdomen will be painful and swollen. Upon palpation or touching it, a lump can be felt due to gallbladder inflammation or malignancy.

3. Lab Test: A routine blood test will be helpful only if there is a presence of an abscess.

4. Imaging Test: It includes -

• Ultrasound or ultrasonography shows the presence of an abscess, gallstones, swelling, etc.

• Computed tomography is done to confirm the diagnosis because it identifies the presence of a fistula or a tract between the gallbladder and the skin.

• Sometimes computed tomography fails to identify the tract and only shows an abnormality. In such cases, a fistulogram is done to identify the tract and confirm the diagnosis.

• Magnetic resonance imaging helps to detect the gallstones, perforations in the skin, and fluids that leak through the abdomen wall.

1. Other Imaging Tests: Sometimes, when a hepatobiliary iminodiacetic acid scan (HIDA) is performed. In this test, a radioactive tracer is injected into the veins. This tracer travels in the body and reaches the liver, where the cells absorb it, which produces the bile. The tracer then goes into the gallbladder and small intestine. Computer images are generated throughout the process with a camera. This helps in evaluating the gallbladder and diagnosing any abnormal condition.

2. Fine Needle Aspiration (FNAC): In the presence of suspected malignancy, fine needle aspiration is performed to identify underlying cancer.

How to Treat the Cholecystocutaneous Fistula?

The severity and occurrence of cholecystocutaneous fistula depend on the patient’s age, medical history, presence or absence of abscess in the abdomen wall, clinical presentation, etc. There is no standard line of management for this condition, and the treatment may vary from patient to patient.

Non-Surgical Treatment:

Generally, non-surgical treatment is given to patients who are elderly and cannot undergo surgery. The initial conservative treatment is important to control the sepsis and drainage.

1. Antibiotic Therapy: In the presence of an abscess, antibiotics will be helpful in managing or treating bacterial infection.

2. Antipyretic and Antiemetics: To subside the fever, nausea, and vomiting.

3. Analgesics: To relieve the pain and discomfort.

4. Incision and Drainage: It is highly recommended to control the drainage of abscesses locally. For this purpose, percutaneous transhepatic gallbladder drainage is performed in which the bile and other fluids are drained out from the abscess with the help of a small tube. This helps to relieve the pressure in the duct.

Surgical Treatment:

After controlling the acute or emergency phase of the cholecystocutaneous fistula and in the absence of malignancy, elective surgery is planned.

1. Elective Cholecystectomy: It is a minimally invasive surgical procedure to remove the gallbladder. There are two types of cholecystectomy methods:

• Open or Traditional Method: An incision of 4-6 inches is made on the upper right side of the abdomen, and the gallbladder is removed by the surgeon.

• Laparoscopic Method: Small multiple incisions are made on the upper right side of the abdomen, and a laparoscope (thin tube with a camera) is inserted. The surgeon visualizes the internal structures on a screen and removes the gallbladder. It is a less invasive method and has lesser recovery time, and is less time-consuming.

2. Removal of Gallstones: Sometimes, when the patient is very old, then only the gallstone is removed with percutaneous treatment - surgery is done through special catheters through small punctures in the skin.

What Are the Complications of Cholecystocutaneous Fistula Surgery?

The possible complications of cholecystocutaneous fistula surgery are:

• Excessive bleeding from the surgery site.

• Infection at the surgery site.

• Injury to the bile duct is a tract or tube that carries bile from the gallbladder to the small intestine.

• Injury to the liver because it is present just above the gallbladder.

• Hernia (bulging of the gallbladder or a part of the organ or tissue into the external skin surface).

• Necrotizing fasciitis is a rare condition in which bacterial infection spreads in the body and causes death.

• Infection and irritation of the surrounding skin.

What Is the Differential Diagnosis of Cholecystocutaneous Fistula?

• Chronic Osteomyelitis of Ribs - Inflammation of bones.

• Tuberculosis or Tuberculoma - A rare condition caused by bacterial spread through abscess discharge and causes tuberculosis.

• Epidermal Cyst - A cyst developed on the skin that becomes infected and inflamed. Usually, it is painless and asymptomatic.

• Metastatic Cancer - A type of cancer that spreads from its origin or source location to other parts of the body.

• Pyogenic Granuloma - Small, reddish bumps on the skin that develop after an injury.

Conclusion:

Cholecystocutaneous fistula rarely occurs as a complication of neglected or untreated calculous cholecystitis, gallstones, and sometimes cancer. The condition is rare, and treatment requires adequate drainage of the abscess. The treatment includes conservative management of the fistula through medications. If the initial treatment fails, then the gallbladder should be removed completely - cholecystectomy. The success or prognosis of cholecystocutaneous fistula is good if the initial management is done properly.