A biliary fistula is suspected in people who have had a history of cholelithiasis, peptic ulcer disease, Crohn's disease, biliary infections (e.g. hydatid disease), malignancies of the gastrointestinal (GI) tract or in those who have recently been surgically operated upon. Most patients are asymptomatic with overt clinical manifestations visible only in 20-30% of cases [1]. Symptoms are usually non-specific and are noticed in a variety of GI disorders. The diagnosis is thus, easily missed in the early stages of the disease.

Amongst individuals who do present with symptoms, abdominal pain may be a frequent finding if the fistula tracts are infected. Other complaints that may be seen include nausea, vomiting, diarrhea, fever, flatulence and weight loss. Cholangitis may lead to systemic manifestations like sepsis and peritonitis. Ascites may be observed in a few people.

Jaundice secondary to common bile duct obstruction or due to strictures of the bile duct (Mirizzi's syndrome) may be recorded [2]. Gallstones may pass into the gastrointestinal tract via these abnormal connections and may cause small bowel obstruction, especially in the terminal ileum (Bouveret's syndrome) [3]. Abdominal pain, vomiting, and constipation ensue in such patients.

In rare instances, fistulas may form between the biliary tree and the pleural/ bronchial spaces with pulmonary complaints occurring in such individuals.

• Soft Tissue Mass

  After antibiotic treatment and surgical opening of both lesions, abdominal computed tomography demonstrated a soft tissue mass cephalad to the umbilicus. We excised the mass, and found it to be associated with a fistula through the linea alba. [ncbi.nlm.nih.gov]

• Chronic Diarrhea

  A pathognomonic triad consisting of pneumobilia, chronic diarrhea, and vitamin K malabsorption was recently suggested by Savvidou and colleagues (2009) to aid in the diagnosis of cholecystocolonic fistula. [clinicalgate.com]

• Biliary Colic

  The hydatid cyst can rupture into the biliary tract, and cyst fluid escapes into the biliary tract with daughter cysts discharged into the common bile duct, causing biliary colic, obstructive jaundice and possibly liver abscess. [ncbi.nlm.nih.gov]

  Interestingly, one third of the patients are absent of prior symptoms of biliary colic and up to 50% have no history of gallbladder disease. [scielo.org.pe]

  colic 胆石仙痛 biliary liver cirrhosis胆汁性肝硬変 biliary tract 胆道 bilirubin ビリルビン boaｒd-like abdomen 板状硬 bougienageブジー拡張術 bowel movement便通 bowel preparation腸管洗浄 brushing cytology擦過細胞診 c cancer of stomach (stomach cancer)胃癌 carbohydrate antigen (CA) 19-9CA 19 [tokyo-med.ac.jp]

• Back Pain

  Right hepatectomy was performed, but on postoperative day 14, the donor developed fever and right back pain, and enhanced CT showed a 6 cm intra-abdominal abscess at the site of cutting, and we diagnosed it as an isolated biliary fistula since the isolated [ncbi.nlm.nih.gov]

Patients presenting with clinical features suggestive of a biliary fistula are often diagnosed via surgery, with preoperative confirmation occurring only in 8-17% of all affected cases [4]. In such a scenario, most investigations are geared towards determining the type of surgery that needs to be conducted. This, in turn, is dependent on the likely etiology of the fistula, the presence of biliary tree obstruction/ erosion and the coexistence of a bilioenteric fistula.

Gallstones, the most common cause of a biliary fistula, are easily diagnosed by a transabdominal ultrasound (US) with a sensitivity of 96% [5]. Similarly, Mirizzi's syndrome can be detected via the transabdominal US with a sensitivity of 29% [4]. Magnetic resonance cholangiopancreatography (MRCP) may offer a higher accuracy in the evaluation of this disorder. It can be used to delineate other abnormalities seen in the biliary tract.

A computed tomography (CT) scan may help in locating the level of biliary tree obstruction. Aerobilia, a frequent sign of a bilioenteric fistula, may be easily observed via US or CT. A CT scan may help to rule out the presence of intestinal obstruction due to biliary stones and/or hepatic neoplasms.

The evaluation of these lesions may be determined by certain invasive studies [6]. Although the usage of endoscopic ultrasound (EUS) for recognizing biliary fistulas is still uncertain, some reports have shown that Mirizzi's syndrome can be reliably confirmed with EUS with 97% sensitivity and 100% specificity [7] [8] [9]. Endoscopic retrograde cholangiopancreatography (ERCP) shows up to 90% accuracy in diagnosing primary biliary fistulas and it may also have a therapeutic role in such cases, assisting in stone retrieval and biliary tract drainage via stents [10].

Laparoscopic cholecystectomy may be used to identify the site, size and potential cause of biliary leaks. A percutaneous transhepatic cholangiography is reserved for people with a completely stenosed biliary tree.

• Nonvisualization of the Gallbladder

  However, a nonvisualized or shrunken gallbladder seen at US often coexisted in these cases. CT yielded the diagnosis in one case of gallstone ileus, and a Gastrografin meal yielded it in the case of Bouveret's syndrome. [ncbi.nlm.nih.gov]

• Ischemic Changes

  Arterio-biliary fistula is a rare clinical condition resulting from various causes such as iatrogenic injury and ischemic change of the bile duct. [ncbi.nlm.nih.gov]

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