What is Cholecystocutaneous Fistula?
A fistula is medically known as an abnormal link between two skin-like surfaces. This abnormal link can happen because of a disease or surgery. The fistula is named after the two surfaces or openings it joins. For example, a cholecysto-cutaneous fistula is an abnormal link between the gallbladder and the skin. Similarly, an entero-cutaneous fistula is an abnormal link between the small bowel and the skin.
A cholecysto-cutaneous fistula is very rare in surgery today. There have been records of spontaneous cholecysto-cutaneous fistulas as far back as the 17th century. This condition usually happens as a problem resulting from long-term gallbladder inflammation caused by gallstones. However, it’s extremely rare in surgeries these days. With improvements in diagnostic imaging, diseases of the bile ducts, through which bile flows from the liver to the gallbladder, are diagnosed early. The ability to perform efficient and safe surgical treatment has made complications like fistulas very rare.
What Causes Cholecystocutaneous Fistula?
A cholecysto-cutaneous fistula is a rare complication that may occur when gallbladder inflammation, often caused by gallstones, is ignored. However, it can also be linked to gallbladder inflammation without stones or to gallbladder cancer.
Many people with this condition don’t have specific symptoms and they often don’t remember having previous gallbladder problems. If gallbladder inflammation is left untreated, the gallbladder wall can start to break down or “necrose.” If the entire wall breaks down, bile can leak into nearby tissue.
One potential place for the bile to leak is the abdominal wall, and then eventually to the skin. This causes what’s known as a cholecysto-cutaneous fistula, which is essentially a direct pathway from the gallbladder to the skin.
Risk Factors and Frequency for Cholecystocutaneous Fistula
Gallbladder fistulas, a rare condition, is generally seen in older women. People with this condition may experience pain in the top right area of their stomach, which can indicate issues related to gallstones. One common symptom is a fistula, or an abnormal connection in the upper area of the abdomen, that is painless and can drain. This can occur in various areas of the belly such as the top right area, near the hip, around the belly button, the lower right back, the lower left area, and even in the buttocks. This condition can sometimes follow a treatment for serious gallbladder disease, and it can reoccur with the opening occurring where previous treatment has taken place.
- Gallbladder fistulas often affect older women.
- Patients may recall having pain in the top right area of their abdomen, possibly indicating gallstones.
- Commonly, a painless, draining opening occurs in the top right part of the belly.
- These openings can appear in different parts of the abdomen, including the top right area, near the hip, around the belly button, the lower right back, the lower left area, and even in the buttocks.
- The condition might arise after treatment for serious gallbladder disease, and it can recur with the fistula forming where the previous treatment occurred.
Signs and Symptoms of Cholecystocutaneous Fistula
People with biliary tract diseases can experience a variety of symptoms depending on their specific condition, age, and whether they have an abdominal wall abscess. A common sign is a persistent sinus discharge, and patients may sometimes expel gallstones through a fistula, a small, abnormal tunnel connecting the inside of the body to the skin’s surface. However, not all patients report these symptoms.
The location of the fistula’s external opening can vary based on its anatomical course. Most commonly, it is found on the upper right side of the abdomen. But it may also be located near the left rib cage, lower right belly, right groin, or right buttock region. The fistula’s discharge can change depending on the underlying condition it is associated with. When the patient has an acute infection or abscess, they may feel unwell or ‘toxic’. Furthermore, a lump may be felt under the skin where the fistula is located due to an inflamed or cancerous gallbladder.
- Persistent sinus discharge
- Expulsion of gallstones through a fistula (in some cases)
- Fistula opening mostly occurs on the upper right side of the abdomen
- Fistula opening can also be located near the left rib cage, lower right belly, right groin, or right buttock region
- Changes in the character of the discharge from the fistula
- Feeling unwell when there is an acute infection or abscess
- Presence of a lump under the skin where the fistula is
Testing for Cholecystocutaneous Fistula
When dealing with gallstone disease, the first step in imaging is often ultrasonography. However, this method hasn’t been found to be significantly helpful in cases of a gallbladder fistula, even though it can clearly show the presence of gallstones. A fistula is an abnormal connection between two parts in your body.
Computed tomography (CT) scans are much more useful for identifying this complication. These scans can show both the gallstones and any connections to the gallbladder. A specific type of CT scan, called a CT fistulogram, can clearly show the fistula connecting to the gallbladder and the biliary tract, which is part of the digestive system.
A CT fistulogram can be performed by injecting diluted contrast, a special dye, into the fistula during the CT scan. This imaging method helps accurately trace the path of the fistula and establish where this path lies in relation to other body structures. It also helps rule out any internal fistula and other related medical issues.
Clear mapping of the fistula is critical for planning the approach and extent of any necessary surgeries. Regular blood tests may not be particularly useful unless there is a build-up of pus, also known as an abscess. MRI with cholangiopancreatography (MRCP), a technique that visualizes the bile ducts, has also been found beneficial in confirming the diagnosis.
Treatment Options for Cholecystocutaneous Fistula
Cholecyst-cutaneous fistula, or an abnormal connection between the gallbladder and the skin, is usually treated initially by draining any related abscess (a pocket of pus) and giving appropriate antibiotics. If there’s a lump or growth associated with the condition, it’s often important to check if it’s cancerous. Fine-needle aspiration cytology (FNAC) is a type of biopsy where a thin needle is used to remove fluid or cells from the lump for testing.
If the test does not show signs of cancer, and there’s no suspicion of cancer, the next step usually involves planning for an operation known as cholecystectomy once the patient’s general health condition is improved. In this surgical procedure, the gallbladder is removed. Surgery is typically performed using an open method that also removes the abnormal tract connecting the gallbladder to the skin.
A ‘keyhole’ method, known as laparoscopic cholecystectomy, can be considered to reduce the risk of complications after the surgery, especially for older patients or those with multiple health issues. In cases when surgery might be risky, such as for elderly or weakened patients with several health problems, treatment might involve removal of the gallstones without removing the gallbladder, typically through a minimally invasive procedure.
Before planning for the main surgery, it’s important to check for any obstruction or stones in the bile ducts, which are tubes that carry bile from the liver to the gallbladder and small intestine.
If a cholecyst-cutaneous fistula arises due to gallbladder cancer with a noticeable lump present, it’s often more difficult to treat. This is because gallbladder cancer tends to spread to neighboring body structures. If this is the case, the overall outcome is usually poor.
What else can Cholecystocutaneous Fistula be?
These conditions are other possibilities when diagnosing various medical issues:
- Chronic osteomyelitis of ribs (a long-lasting infection in the ribs)
- Discharging tuberculoma (a type of tuberculosis lesion)
- Infected epidermal inclusion cyst (a type of skin cyst that has become infected)
- Metastatic carcinoma (cancer that has spread to other parts of the body)
- Pyogenic granuloma (a type of skin lesion)
What to expect with Cholecystocutaneous Fistula
The outlook for a condition known as cholecystocutaneous fistula, a small tunnel that forms between the gallbladder and the skin, is typically quite positive. However, complications can arise in older individuals who have other existing health conditions. It’s rare, but there can sometimes be a shift in the fistula towards a cancerous state.
Possible Complications When Diagnosed with Cholecystocutaneous Fistula
Common Complications:
- Flesh-eating disease (Necrotizing fasciitis)
- Skin irritation
- Development of cancers (Malignant changes)
Preventing Cholecystocutaneous Fistula
When patients leave the hospital, it’s important they know how to take care of their surgical wound properly and have regular follow-up appointments. This is crucial to prevent further health problems, like infections or sepsis, which is a serious condition where the body reacts to an infection affecting the whole body.