Biliary fistulas: causes, symptoms, diagnosis, treatment

External bile fistulae

External bile fistulas are usually formed after such interventions on the biliary tract, such as cholecystotomy, transhepatic drainage of the bile ducts and drainage of the common bile duct by means of a T-tube. Very rarely fistulas can form as a complication of cholelithiasis, gallbladder cancer, or trauma to the biliary tract.

Due to the loss of sodium and bicarbonate with bile in patients with external bile fistulas, severe hyponatremic acidosis and hyperammonemia can develop. Obstruction of the biliary tract distal to the fistula prevents its healing. In such cases, the endoscopic or transcutaneous stent placement allows closure of the fistula without a complicated re-operation

Internal bile fistulae

In 80% of cases, the cause of internal bile fistulas is the prolonged existence of calculous cholecystitis. After soldering the inflamed gallbladder with the intestinal tract (usually the duodenum, less often the colon) and the formation of the fistula, stones enter the lumen of the intestine and can completely cover it (gall-stone intestinal obstruction). This usually occurs in the terminal ileum.

Postoperative stricture of the biliary tract, especially after repeated attempts to eliminate them, can be complicated by the formation of fistulas, often liver-duodenal or liver-gastric. Such fistulas are narrow, short and easily blocked.

The fistula can develop as a result of penetration into the gallbladder or common bile duct of chronic duodenal ulcer, colon ulcers with ulcerative colitis or Crohn's disease, especially if the patient has received corticosteroids.

In rare cases, the stone can lead to the formation of a fistula between the hepatic duct and portal vein with massive hemorrhage, shock and death of the patient.

Symptoms of bile fistulae

The disease is preceded by a long history of cholelithiasis. Fistulas can be asymptomatic, self-closing after the stone has left the intestine. In such cases, they are diagnosed during cholecystectomy.

Approximately one third of patients in the anamnesis or on admission to the hospital have jaundice. Pain may be absent, but sometimes expressed in intensity, resembles biliary colic. There may be symptoms of cholangitis. With cholecysto-fistula fistula, the common bile duct is filled with stones, putrefactive and calves, which leads to severe cholangitis. The entry of bile salts into the intestine is the cause of profuse diarrhea and a marked decrease in body weight.

Diagnosis of bile fistulas

X-ray signs include the presence of gas in the biliary tract and the unusual location of the calculi. Yellow ways can be contrasted after oral administration of barium (with cholecystoduodenal fistulas) or after a barium enema (with cholecysto-fistula fistula). In some cases, the swollen small intestine is revealed.

Usually, fistula is visualized by ERCP.

Treatment of bile fistulas

With fistulas that develop as a result of diseases of the gall bladder, surgical treatment is necessary. After separation of the involved organs and closure of defects in their wall, cholecystectomy and drainage of the common bile duct are performed. The operational mortality is high and is about 13%.

Closure of cholecystectomy and bronchobiliary fistulas can occur after endoscopic removal of choledocha stones. Intestinal obstruction caused by a gallstone.

A gallstone larger than 2.5 cm in diameter, entering the intestine, causes obstruction, usually at the level of the ileum, less often at the duodenal-junction level, the bulb of the duodenum, pyloric department or even the colon. As a result of infringement of a stone inflammatory reaction of a wall of a gut or invagination develops.

Intestinal obstruction due to gallstones is very rare, but in patients older than 65 years, gallstones cause obturation intestinal obstruction in 25% of cases.

Complication is usually observed in elderly women with chronic cholecystitis in anamnesis. Intestinal obstruction develops gradually. Accompanied by nausea, sometimes vomiting, cramping pains in the abdomen. At palpation the stomach is swollen, soft. Body temperature is normal. Full gut obturation with a stone leads to a rapid deterioration of the condition.

On the overview radiograph of the abdominal cavity, you can see swollen loops of the intestine with fluid levels, sometimes a stone that caused obstruction. The presence of gas in the bile duct and gall bladder indicates a bile fistula.

Survey radiography on admission allows diagnosis in 50% of patients, another 25% of patients diagnosed with ultrasound, CT or radiological examination after taking a barium suspension. In the absence of cholangitis and fever, leukocytosis, as a rule, is not noted.

Before laparotomy gallstones intestinal obstruction can be diagnosed in 70% of cases.

The prognosis of the disease is poor and deteriorates with age.

After correction of water-electrolyte disorders, intestinal obstruction is surgically removed. The stone is pushed into the lower parts of the intestine or extracted by enterotomy. If the patient's condition and the nature of the lesions of the biliary tract are allowed, cholecystectomy and fistula closure are performed. Lethality is about 20%.