PMC6796697_01
a. coronal section of abdominal CT scan demonstrating thickening extending from the gallbladder to the hepatic flexure of the colon b. transverse section of findings described in 1a.
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Due to extensive ring-down artifact on US, computed tomography (CT) imaging was obtained and elicited concern for cholecystocolonic fistula (Fig. 1); with pneumobilia, inflammation and enhancement in the area of the gallbladder fossa and common bile duct (CBD), as well as thickening extending into the adjacent colon at the hepatic flexure.
Preoperative Hepatic Scintigraphy suggestive of biliary flow to the colon through cholecystocolonic fistula in addition to its trajectory through the biliary tree.
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Hepatobiliary scintigraphy was compatible with a cholecystocolonic fistula to the hepatic flexure of the colon (Fig. 2). However, preoperative colonoscopy was unable to locate the fistula tract.
ERCP indicating multiple filling defects in the hepatic ducts and suggestive of a large stone eroding through the wall of the upper third of the common hepatic duct, concerning for Mirizzi type IV.
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The patient underwent a diagnostic ERCP and was found to have multiple stones in the hepatic ducts as well as a large stone eroding through the wall of the upper third of the common hepatic duct concerning for Csendes type IV Mirizzi syndrome (Fig. 3); stent was placed in the CBD.
Intraoperative photos during exploratory laparotomy and bile duct exploration with choledochotomy. a. choledochotomy revealing large stone previously eroding through the upper one-third of the common hepatic duct. b. gallbladder remnant repaired following choledochotomy.
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The stent was visible in the lumen of the bile duct (Fig. 4a) and the remainder of the gallbladder neck was used to primarily repair the defect using interrupted sutures (Fig. 4b).