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

Peng, Chia-Huei*; Wei, Chin-Hung; Yeung, Chun-Yan*,†,§

Journal of Pediatric Gastroenterology and Nutrition: March 2018 - Volume 66 - Issue 3 - p e81
doi: 10.1097/MPG.0000000000001152
Image of the Month

*Department of Pediatrics

Department of Pediatric Gastroenterology and Nutrition

Department of Pediatric Surgery, Mackay Children's Hospital

§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:

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, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

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).

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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; 17:104–108.
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; 19:172–174.
4. Jorge A, Diaz M, Lorenzo J, Jorge O. Choledochoduodenal fistulas. Endoscopy 1991; 23:76–78.
© 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,