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Cholecysto-colonic fistula after xanthogranulomatous cholecystitis: Surgeon’s nightmare

Xanthogranulomatous cholecystitis is a rare benign in lammatory disease of gallbladder that may be misdiagnosed as carcinoma of the gallbladder intraoperative or in preoperative imaging. Intramural accumulation of lipid-laden macrophages and acute and chronic in lammatory cells is the hallmark of the disease. The xanthogranulomatous in lammation can be very severe and can spill over to the neighboring structures like liver, bowel and stomach resulting in dense adhesions, abscess formation, perforation, and istulous communication with adjacent bowel [1-3]. Cholecysto-colic istula is a rare and late complication of gallstones roughly found 1 in every 1,000 cholecystectomies.


Introduction
Xanthogranulomatous cholecystitis is a rare benign in lammatory disease of gallbladder that may be misdiagnosed as carcinoma of the gallbladder intraoperative or in preoperative imaging. Intramural accumulation of lipid-laden macrophages and acute and chronic in lammatory cells is the hallmark of the disease. The xanthogranulomatous in lammation can be very severe and can spill over to the neighboring structures like liver, bowel and stomach resulting in dense adhesions, abscess formation, perforation, and istulous communication with adjacent bowel [1][2][3]. Cholecysto-colic istula is a rare and late complication of gallstones roughly found 1 in every 1,000 cholecystectomies.

Clinical features
The clinical features are variable and non-speci ic. Patients with cholecysto-colonic istula often present with symptoms of acute cholecystitis and preoperative diagnostic tools often fail to show the istula. Hence most cases it is an on table diagnosis.

Management
Treatment involves closing the istula and performing an open or laparoscopic cholecystectomy.

Case report
40 year old male patient with nil premorbid illness came with complains of pain in upper abdomen since 20 days. No history of fever, jaundice or bowel/bladder disturbance. Clinical examination was unremarkable. Routine blood investigations including total leucocyte count, bilirubin levels were with in normal limits. Ultrasound abdomen and pelvis showed features suggestive of perforated gall bladder. Patient underwent CECT abdomen and pelvis (Figure 1a-c) which showed perforated emphysematous cholecystitis with cholelithiasis.
Patient was managed conservatively with intravenous antibiotics. Patient had uneventful recovery from this attack of acute cholecystitis and was called after 6 weeks for elective laparoscopic cholecystectomy.
Patient was admitted after 6 weeks for elective laparoscopic cholecystectomy. Patients liver function test and total leucocyte count preoperatively were within normal limits. Repeat ultrasound abdomen and pelvis showed multiple gall stones with wall of gall bladder not clearly appreciated.
The exact etiology of cholecysto-colonic istula secondary to gallstone disease is unclear. Glenn, et al. [9] proposed that acute in lammation of the gallbladder with obstruction of the cystic duct allows adhesion of the gallbladder to the contiguous organs. Recurrent acute cholecystitis promotes ulceration and ischemia of the wall of the gallbladder and the adjacent organs, resulting in further erosion and ultimately istulation.
The most common presenting symptoms of nonobstructing biliary-enteric istulas are abdominal pain, nausea, and diarrhea. These can be explained by the fact that cholecysto-colonic istula alters enterohepatic circulation, leading to a malabsorption syndrome [8]. A cholecystocolonic istula can cause a large-bowel obstruction with stone impaction at rectosigmoid diverticula [8].
Preoperative studies may include ultrasound, CT scan, MR, ERCP, and barium enema, but a proper diagnosis is often achieved intraoperative [10]. Pneumobilia may give a suspicion of cholecysto-colonic istula [8] especially if the gallbladder is atrophic and anatomically adjacent to another organ on computed tomography or ultrasound. However, Yamashita, et al. [11] reported that ERCP was the most accurate diagnostic modality of cholecysto-colonic istula. Wang, et al. [12] were able to illustrate cholecysto-colonic istula using ultrasound, ERCP, and magnetic resonance imaging techniques in 50% of cases.

Conclusion
Laparoscopic cholecystectomy following an episode of cholecystitis especially after xanthgranulomatous in lammation requires extreme care to identify and treat istulas to avoid life-threatening events thereafter.