Evolution of entero-biliary fistula following gallstone ileus management.

DESCRIPTION A healthy 78-year-old man was admitted with a 3-day history of epigastric pain and bilious vomiting. Ultrasound revealed cholelithiasis with a normal calibre common bile duct. The patient subsequently underwent an upper gastrointestinal endoscopy which demonstrated a large duodenal defect consistent with an entero-biliary fistula (figure 1). Abdominal CT demonstrated small bowel dilatation (large arrow, figure 2), large calcifications within the small bowel and pneumobilia (small arrow, figure 2) consistent with gallstone ileus. The patient underwent a laparotomy and enterolithotomy. The choledocho-duodenal fistula was not disturbed. He had an unremarkable recovery. A repeat upper gastrointestinal endoscopy 4 months later demonstrated that the duodenal defect had completely healed (figure 3). Considerable controversy exists in the surgical literature about the appropriate management of choledocho-duodenal fistula at laparotomy for gallstone ileus. These images demonstrate for the first time, spontaneous healing of an entero-biliary fistula in a patient with gallstone ileus.