EP.TU.581Cholecysto-colonic fistula – A rare complication of gallstone

We present a 90year old male patient presenting to the emergency department with complaints of PR bleed for a month with no associated abdominal pain. He described that the blood was mixed with stools and dark in colour. He has a significant past medical history with multiple comorbidities. The patient is known to have gallstones and had ERCP with sphincterotomy in 2017 as a definitive treatment, as he wasn’t a fit candidate for surgical intervention. On clinical examination, his abdomen was soft and non-tender and per rectal examination showed stools mixed with the blood but no active bleeding or fresh blood. His haemoglobin was 72 g/L, inflammatory markers were significantly elevated with deranged liver enzymes and normal bilirubin. The medical team were involved in the management of this patient because of pneumonia and extensive medical issues. A gastroscopy was performed as there was a suspicion of UGI bleed, which was normal. Given a deranged liver function and there was a suspicion of biliary sepsis patient had MRCP and Computed tomography of the abdomen which confirmed that there is haematoma in the gallbladder with gas in the biliary tree, with possible cholecysto-colonic fistula, with a large gall stone (2.7cm lamellated structure within rectum) in the rectum. As the patient was not a surgical candidate decision was made to manage him conservatively with antibiotics under medical care. The cholecysto-colonic fistula is a rare complication of gallstone disease, and very few cases have been reported in the literature.

Cases of gastro-colonic fistula due to postoperative peptic ulcer of the jejunum

The issue I have touched upon has already been repeatedly debated on the pages of the medical press in order to clarify the method of surgical intervention for severe complications of such a relatively safe operation as the imposition of a gastrointestinal fistula for gastric ulcer and duodenal ulcer.

A242 THE AIR BETWEEN US: A CASE OF PSEUDOCYST PERFORATION POST-ENDOSCOPIC CLIPPING OF A BLEEDING PANCREATIC-COLONIC FISTULA

Background Pancreatic fistula is an uncommon complication of pancreatitis and is associated with increased morbidity. We discuss a case of pancreatic-colonic fistulization followed by the first reported case of pseudocyst perforation post-colonoscopy. Aims Case Methods A 51 year-old female with decompensated alcoholic cirrhosis admitted with hepatic encephalopathy developed large volume hematochezia during admission. Past medical history includes pancreatic pseudocyst, GERD and remote hernia repairs. For the hematochezia, she was investigated with an EGD and colonoscopy. In the distal descending colon, a bleeding lesion was identified and treated with clips and epinephrine injection (Figures 1 and 2). Five hours post-procedure, she developed abdominal distention. CT abdomen pelvis revealed large volume of free air and simple fluid within the abdominal cavity likely secondary to rupture pseudocyst rupture. The previously visualized pseudocyst was filled with gas plastered against the descending colon. She remained medically stable with conservative management. Results Discussion Conclusions Pancreatic-colonic fistula is an uncommon but potentially life-threatening complication of acute pancreatitis associated with high risk of complications. They are found in 4% of admitted inpatients with acute pancreatitis. There are three proposed mechanisms for their development: firstly, inflammation and activated pancreatic lytic enzymes; secondly, pressure necrosis from a contiguous mass; thirdly, localized portal hypertension. Classically, pancreatic-colonic fistulas present with diarrhea, fever and hematochezia. Gastrointestinal bleeding occurs in 60% of cases. The source of bleed has been described to be originating most commonly from the splenic artery and to a lesser extent, the margin of the fistula or, rarely, erosion of splenic parenchyma. Reported therapeutic management strategies include: hemoclippings and Greenplast sprayings, endoscopic pancreatic stent, transgastric nasocystic drainage catheter placements, injection of N-butyl-2-cyanocrylate and transpapillary nasopancreatic drainage. Pseudocysts arise in 25% of patients with chronic pancreatitis. Pseudocysts may regress through a variety of mechanisms: spontaneously after inflammation from pancreatitis resolves, natural drainage through the pancreatic duct into the duodenum, or through a complicating fistulous tract connecting to the gastrointestinal tract. Rarely, the pseudocyst can resolve as it leaks or perforates into the abdominal cavity. Pancreatic pseudocysts may perforate spontaneously into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity, or through the abdominal wall. We report the first case, to our knowledge, of pancreatic pseudocyst perforation post-clipping of bleeding pancreatic-colonic fistula. Funding Agencies None