Biliary-enteric Fistula, A Rare Complication of Peptic Ulcer Disease in Children

Biliary-enteric Fistula, A Rare Complication of Peptic Ulcer Disease in Children IMAGE OF THE MONTH FIGURE 1. Upper endoscopy showed multiple areas of cobblestone mucosa in the friable antrum (A); deformed pylorus (B); the same friability, cobblestone appearance, and ulcers were also found at the duodenum (C). FIGURE 2. Upper gastrointestinal contrast study showed contrast material flowing through the fistula from the duodenum into the gallbladder. A 14-year-old boy presented with abdominal pain and hematemesis, after 2 years of occasional vague epigastralgia. Radiographs showed no evidence of perforation; hepatobiliary ultrasound showed an inflamed gallbladder (GB) and a hypoechoic ill-defined mass shadow. Computed tomography revealed a distinct air bubble in the edematous GB, suspicious for a biliary-enteric fistula (BEF). Upper endoscopy showed cobblestone mucosa with ulcerations in the antrum and duodenum (Fig. 1). Helicobacter pylori test was negative. Symptoms persisted despite proton-pump inhibitor. Magnetic resonance cholangiopancreatography demonstrated a stretching appearance of the cystic duct, fluid accumulation in the GB fossa, and wall thickening and luminal narrowing in the pre- and postpyloric region. Exploratory laparoscopy elucidated severe adhesions between the pylorus, duodenum, and GB, but no fistula. The sonographic mass appeared to be localized fibrosis because of chronic inflammation. A subsequent contrast study demonstrated a fistula between the GB and proximal duodenum (Fig. 2). BEFs between the GB and an adjacent hollow viscus may be due to cholecystitis and/or gallstones (1). In this case, the BEF appears to result from micropenetration of chronic peptic ulcers, reported to account for 5% of cases (2). Diagnosis is made by computed tomography for pneumobilia, contrast radiology or MRCP for localization, and ERCP allowing simultaneous treatment (3,4). Submitted by: z y§ Chia-Huei Peng, Chin-Hung Wei, and Chun-Yan Yeung { { Department of Pediatrics, Department of Pediatric Gastroenterology and Nutrition, Department of Pediatric Surgery, Mackay Children’s Hospital, and Department of Medicine, Mackay Medical College, Taipei, Taiwan. Address correspondence and reprint requests to Chun-Yan Yeung, MD, PhD, Department of Pediatric Gastroenterology and Nutrition, Mackay Children’s Hospital, No. 92, Sec. 2, Zhongshan N Rd, Taipei 10449, Taiwan (e-mail: cyyeung@mmh.org.tw). The authors report no conflicts of interest. Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal. REFERENCES 1. Mittendorf EA. Image of the month—diagnosis. Arch Surg 2004;139:908. 2. Xeropotamos NS, Nousias VE, Vekris AD, et al. Choledochoduodenal fistula: an unusual complication of penetrated duodenal ulcer disease. Ann Gastroenterol 2004;17:104 – 8. 3. Duman L, Savas C, Aktas AR, Akcam M. Choledochoduodenal fistula: An unusual cause of recurrent cholangitis in children. J Indian Asso Pediatr Surg 2014;19:172 – 4. 4. Jorge A, Diaz M, Lorenzo J, Jorge O. Choledochoduodenal fistulas. Endoscopy 1991;23:76 – 8. Copyright 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000001152 JPGN Volume 66, Number 3, March 2018 e81 Copyright © ESPGHAN and NASPGHAN. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Pediatric Gastroenterology & Nutrition Wolters Kluwer Health

Biliary-enteric Fistula, A Rare Complication of Peptic Ulcer Disease in Children

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Wolters Kluwer Health
Copyright
Copyright 2016 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
ISSN
0277-2116
eISSN
1536-4801
D.O.I.
10.1097/MPG.0000000000001152
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Abstract

IMAGE OF THE MONTH FIGURE 1. Upper endoscopy showed multiple areas of cobblestone mucosa in the friable antrum (A); deformed pylorus (B); the same friability, cobblestone appearance, and ulcers were also found at the duodenum (C). FIGURE 2. Upper gastrointestinal contrast study showed contrast material flowing through the fistula from the duodenum into the gallbladder. A 14-year-old boy presented with abdominal pain and hematemesis, after 2 years of occasional vague epigastralgia. Radiographs showed no evidence of perforation; hepatobiliary ultrasound showed an inflamed gallbladder (GB) and a hypoechoic ill-defined mass shadow. Computed tomography revealed a distinct air bubble in the edematous GB, suspicious for a biliary-enteric fistula (BEF). Upper endoscopy showed cobblestone mucosa with ulcerations in the antrum and duodenum (Fig. 1). Helicobacter pylori test was negative. Symptoms persisted despite proton-pump inhibitor. Magnetic resonance cholangiopancreatography demonstrated a stretching appearance of the cystic duct, fluid accumulation in the GB fossa, and wall thickening and luminal narrowing in the pre- and postpyloric region. Exploratory laparoscopy elucidated severe adhesions between the pylorus, duodenum, and GB, but no fistula. The sonographic mass appeared to be localized fibrosis because of chronic inflammation. A subsequent contrast study demonstrated a fistula between the GB and proximal duodenum (Fig. 2). BEFs between the GB and an adjacent hollow viscus may be due to cholecystitis and/or gallstones (1). In this case, the BEF appears to result from micropenetration of chronic peptic ulcers, reported to account for 5% of cases (2). Diagnosis is made by computed tomography for pneumobilia, contrast radiology or MRCP for localization, and ERCP allowing simultaneous treatment (3,4). Submitted by: z y§ Chia-Huei Peng, Chin-Hung Wei, and Chun-Yan Yeung { { Department of Pediatrics, Department of Pediatric Gastroenterology and Nutrition, Department of Pediatric Surgery, Mackay Children’s Hospital, and Department of Medicine, Mackay Medical College, Taipei, Taiwan. Address correspondence and reprint requests to Chun-Yan Yeung, MD, PhD, Department of Pediatric Gastroenterology and Nutrition, Mackay Children’s Hospital, No. 92, Sec. 2, Zhongshan N Rd, Taipei 10449, Taiwan (e-mail: cyyeung@mmh.org.tw). The authors report no conflicts of interest. Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal. REFERENCES 1. Mittendorf EA. Image of the month—diagnosis. Arch Surg 2004;139:908. 2. Xeropotamos NS, Nousias VE, Vekris AD, et al. Choledochoduodenal fistula: an unusual complication of penetrated duodenal ulcer disease. Ann Gastroenterol 2004;17:104 – 8. 3. Duman L, Savas C, Aktas AR, Akcam M. Choledochoduodenal fistula: An unusual cause of recurrent cholangitis in children. J Indian Asso Pediatr Surg 2014;19:172 – 4. 4. Jorge A, Diaz M, Lorenzo J, Jorge O. Choledochoduodenal fistulas. Endoscopy 1991;23:76 – 8. Copyright 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000001152 JPGN Volume 66, Number 3, March 2018 e81 Copyright © ESPGHAN and NASPGHAN. All rights reserved.

Journal

Journal of Pediatric Gastroenterology & NutritionWolters Kluwer Health

Published: Mar 1, 2018

References

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