Rare presentation of primary coloduodenal fistula

We report a case involving a 54-year-old female office administrator, who presented to A&E with a 5-day history of multiple episodes of vomiting (in the last 24 hours it had become feculent), upper abdominal pain, tenderness and generally being unwell. On clinical examination, patient had epigastric and right upper quadrant abdominal pain and tenderness. The abdomen was not distended. Bowel sounds were active. Blood results showed haemoglobin of 15.4 g/dl, White cell count of 11.7 10^9/l, Neutrophils of 9.4 10^9/l and a Calcium of 2.7 mmol/l. C-reactive protein and the rest of the biochemical profile were normal. An abdominal film did not reveal any obvious pathology (Images 1 and 2). Patient had initially presented to her GP with a history of vague abdominal pain, diarrhoea and vomiting. Her symptoms were attributed to stress at work and depression. She was started on PPI and anti-sickness medication. As the symptoms did not settle and the patient developed right upper quadrant pain, she was investigated with Ultrasound (US), diagnosed with gall stone disease and was referred to the general surgical clinic for consideration of laparoscopic cholecystectomy. Her past medical history included investigation for endometriosis and treatment for depression. She had a family history of scleroderma (two 1st degree relatives), breast cancer (1st and 2nd degree relatives), Raynaud’s disease (two 1st degree relatives) and multiple sclerosis. While she was waiting for a clinic appointment, she was admitted to the hospital with acute cholecystitis and had conservative treatment. At that time she had raised inflammatory markers and US showed thickened gall bladder containing stones and nothing else. She was discharged and placed on waiting list for a cholecystectomy. During her admission a history of weight loss and lethargy was noted. The patient was referred for outpatient computer tomography (CT) examination to exclude malignancy. CT reported thickening of the wall of the hepatic flexure and transverse colon suggestive of colitis, but its exact significance was uncertain. A colonoscopy was organized with a view to obtaining a definite diagnosis, but the patient was acutely unwell again and had to be admitted. By this time it was more than 6 months since the initial symptoms began. Patient was monitored and treated with intravenous fluids, nasogatric tube, input and output monitoring. After 24 hours her condition was found to deteriorate. Based on results of recent CT scan, our first differential diagnosis was an obstructive upper Gastrointestinal (GI) neoplasm. It was decided not to have further preoperative CT scan as it would not add additional diagnostic value but only delay definitive treatment. Patient was taken for surgery. Intraoperative findings were – a large inflammatory mass in right upper quadrant area which involved the proximal transverse colon, third part of duodenum, and part of the liver medial to the gall bladder bed. Dissection revealed a DECLARATIONS