Background

Within the medical field, a fistula is defined as an irregular joining of two epithelial surfaces that may result from an illness or surgical operation. A fistula’s name corresponds to the two lumens or surfaces it connects. Thus, a cholecysto-cutaneous fistula represents an irregular relationship between the skin and the gallbladder, whereas an entero-cutaneous fistula represents an irregular relationship between the skin and the small intestine. 

In surgical practice, cholecysto-cutaneous fistulas are now uncommon. Records from the past attest to cases of spontaneous cholecysto-cutaneous fistulae that occurred as early as the 17th century. This disease usually develops as a consequence of untreated calculous cholecystitis, but it is extremely rare in modern surgical cases.

In the modern period, improvements in medical imaging have made it easier to identify biliary tract disorders early on. The incidence of problems such as fistulas has been greatly reduced by the readily available safe and effective surgical procedures. 

Epidemiology

Cholecystocutaneous fistulas (CCFs) are rare. The average age at diagnosis is 72.8 years, and the majority of patients affected are elderly females (18/29 male-to-female ratio). 

The complications of untreated gallbladder illness are frequently the cause of CCF. Most instances have chronic calculus cholecystitis as their presenting symptom, and some have a history of previous surgical treatments (e.g., subtotal cholecystectomy for acute cholecystitis). 

The pathophysiological process behind CCF is frequently associated with elevated gallbladder pressure subsequent to calculus cholecystitis, which in turn leads to the creation of fistulas. Although gallbladder bacterial infections account for the majority of CCF occurrences, gallbladder adenocarcinomas can also cause CCF. 

Escherichia coli is the most common microorganism in cholecystocutaneous fistula cases, followed by Klebsiella pneumonia and Coliforms. Furthermore, the retention of stones during the procedure of laparoscopic cholecystectomy and traumatic gallbladder rupture are risk factors for cholecystocutaneous fistula. 

Anatomy

Pathophysiology

The pathophysiology of this condition’s development is believed to be significantly influenced by gallstone blockage of the biliary outflow. A blocked cystic duct causes the intra-gallbladder pressure to rise. Unresolved bile outflow obstruction compromises lymphatic drainage and blood circulation in the gallbladder wall, ultimately leading to gallbladder wall necrosis.

The gallbladder pericholecystic abscess then perforates openly. When the gallbladder is punctured, it may empty into the peritoneum and cause a Perito-ni localized abscess. Because of the abscess’s adhesion to the abdominal wall, it may eventually turn into an external fistula. It uses the quickest path or area of lowest resistance to evacuate its contents.

Predisposing variables could include trauma, typhoid, polyarteritis nodosa, or medication therapies like steroids. It is known that gallbladder cancer can manifest as an external fistula. Usually, chronic biliary tract illness develops into a late sequela of cutaneous gallbladder fistula. It has also been documented following insufficient management of acute cholecystitis. 

Etiology

An infrequent consequence of untreated calculous cholecystitis is the development of cholecystocutaneous fistulas. Furthermore, this condition has been associated with gallbladder cancer or acalculous cholecystitis. A noteworthy proportion of individuals affected by this ailment initially experience nonspecific symptoms and rarely disclose a prior history of gallbladder issues.

When the inflamed gallbladder wall is left untreated, necrosis sets in. Complete wall necrosis results in bile leakage into the surrounding tissue. Leakage may occur in various locations, with the abdominal wall being one potential site, ultimately leading to the formation of a cholecysto-cutaneous fistula in the overlying skin. 

Genetics

Prognostic Factors

Numerous factors can affect the cholecystocutaneous fistula prognosis, which is characterized by an improper connection between the skin and the gallbladder. While each case is distinct, and prognostic determinants may differ, the following are considerations that can affect the overall outlook: 

Timely Diagnosis and Treatment: 

Early detection of the cholecystocutaneous fistula and prompt initiation of appropriate treatment can significantly impact the prognosis. Delays in diagnosis or treatment may result in complications and influence outcomes. 

Underlying Gallbladder Disease: 

The root cause of the cholecystocutaneous fistula, such as chronic calculous cholecystitis or other gallbladder diseases, can affect the prognosis. For a successful conclusion, the underlying problem must be addressed and managed. 

Complications and Infections: 

The presence of complications, such as infections in the gallbladder or surrounding tissues, can influence prognosis. Timely management of complications and infections is essential to prevent further issues and enhance the prognosis. 

Overall Health of the Patient: 

The prognosis is influenced by the patient’s overall health and condition. Patients with better overall health may respond more positively to treatment and exhibit a better prognosis. 

Surgical Intervention and Reconstruction: 

The success of surgical procedures, including the closure of the fistula and the reconstruction of biliary and skin structures, can impact the prognosis. The proficiency of the surgical team and the appropriateness of the chosen surgical approach are crucial factors. 

Microbial Infections: 

The type and severity of microbial infections associated with the cholecystocutaneous fistula can impact prognosis. The choice of antibiotics and the effectiveness of infection management play a role in the overall outcome. 

Patient Compliance and Follow-Up: 

The patient’s adherence to postoperative care, medications, and follow-up appointments is critical for a positive prognosis. Complying with medical recommendations can help prevent recurrence and manage potential complications. 

Clinical History

The clinical manifestation of a cholecystocutaneous fistula, an infrequent medical condition characterized by an abnormal connection between the gallbladder and the skin, can exhibit variability, and symptoms may not always be clear-cut. The presentation may encompass the following elements: 

Skin Abnormalities: 

Drainage or Discharge: 

• A prominent indication is the presence of continuous drainage or discharge from the skin, often situated over the abdominal region. The discharge may contain bile, pus, or other fluids. 

Pain and Tenderness: 

Abdominal Pain: 

• Patients may encounter abdominal pain or discomfort, typically concentrated in the vicinity of the gallbladder. 

Tenderness: 

• Palpation of the affected area may unveil tenderness, particularly around the opening in the skin. 

Skin Infections: 

Erythema and Swelling: 

• Inflammation of the skin adjoining the fistula site may result in redness and swelling. 

Infection Signs: 

• Indications of localized infection, such as heightened warmth and increased pain, may be evident. 

Gallbladder Disease Symptoms: 

Nausea and Vomiting: 

• Symptoms associated with gallbladder disease, such as nausea and vomiting, may be observable. 

Fever: 

• In instances of infection, patients may develop a fever. 

Systemic Symptoms: 

Malaise: 

• A general sense of discomfort or malaise may be communicated. 

Weight Loss: 

• Unintentional weight loss might occur, particularly if complications or chronic inflammation are present. 

Previous Medical History: 

Gallbladder Issues: 

• Patients may possess a medical history involving gallbladder problems, such as chronic calculous cholecystitis. 

Prior Surgical Interventions: 

• Individuals with a history of past surgeries, particularly cholecystectomy, may be predisposed to the development of a fistula. 

Physical Examination

The physical examination of a cholecystocutaneous fistula entails a comprehensive evaluation of the affected region to discern indicators and symptoms linked to the abnormal connection between the gallbladder and the skin. Below are the essential components of the physical examination: 

Inspection: 

Skin Opening: 

• Scrutinize the abdominal skin for visible openings or fistula tracts, paying attention to indications of drainage or discharge. 

Erythema and Swelling: 

• Examine the surrounding skin for signs of redness and swelling, potential indicators of inflammation. 

Palpation: 

Tenderness: 

• Delicately palpate the region surrounding the skin opening and the presumed path of the fistula tract, taking note of any reported tenderness or discomfort. 

Induration: 

• Assess for areas of induration (hardening) around the site of the fistula. 

Drainage Examination: 

The character of Discharge: 

• Evaluate the features of any drainage or discharge from the skin opening, including color, consistency, and odor. Bile, pus, or other fluids may be present. 

Collection of Discharge: 

• Consider obtaining a sample for laboratory analysis, especially if there are suspicions of infection. 

Abdominal Examination: 

Localize Pain: 

• Ascertain the presence of localized abdominal pain, particularly in the vicinity around the gallbladder. 

Guarding or Rigidity: 

• Inspect for signs of abdominal guarding or rigidity, potential indicators of inflammation or infection in the abdominal cavity. 

Systemic Signs: 

Fever: 

• Measure the patient’s body temperature to detect any systemic signs of infection. 

General Well-being: 

• Evaluate the patient’s overall appearance, searching for signs of malaise or discomfort. 

Review of Medical History: 

Gallbladder History: 

• Inquire about any prior history of gallbladder issues, such as chronic calculous cholecystitis. 

Surgical History: 

• Explore the patient’s surgical background, including any previous cholecystectomy or other abdominal procedures. 

Diagnostic Imaging: 

Consideration for Imaging: 

• Based on the clinical findings, contemplate ordering imaging studies like ultrasound, CT scan, or MRI to visualize the extent of the cholecystocutaneous fistula and evaluate associated structures. 

Diagnosing CCF typically involves employing imaging studies, with exploratory laparotomy being reserved for specific cases. The imaging modalities encompass Ultrasonography (US), Computed Tomography (CT), Fistulogram, and Magnetic Resonance Imaging (MRI). 

Ultrasonography (US) proves effective in evaluating CCF and uncovering anomalies such as abscesses, gallbladder stones, edema, thickening of the gallbladder wall, and dilated biliary ducts. Nevertheless, the US may not consistently confirm the CCF diagnosis and occasionally reveals the fistula track. 

CT plays a more significant role than the US in pinpointing the fistula track, affirming the diagnosis by visualizing the connection between the gallbladder and the skin. CT fistulogram enhances diagnostic certainty by illustrating the fistula track. In certain instances, CT may indicate abnormal findings suggestive of the diagnosis without distinctly identifying the fistula track. 

MRI adeptly detects gallstones, gallbladder perforation, and extruded fluid through the abdominal wall. Its utility is particularly evident when CT reveals no abnormalities. Magnetic Resonance Cholangiopancreatography (MRCP) produces results akin to US and CT, thereby contributing to an increased number of confirmed cases. 

The use of hepatobiliary iminodiacetic acid scan in two cases proved unsuccessful in demonstrating the fistula in one instance and indicated biliary tract obstruction in the other. 

Exploratory laparotomy may serve as the primary diagnostic method, particularly in historical cases, resource-limited environments, or situations lacking laparoscopic expertise and appropriate equipment. 

While CT Fistulogram or X-ray Fistulogram accurately displays the fistula track, their consistent use in diagnosis is not prevalent, and alternative methods are frequently employed. 

Challenges in the diagnosis include a shortage of radiological expertise, the rarity of CCF leading to its infrequent consideration in differential diagnoses, and the presence of mucous discharge, rather than yellowish discharge, in cases of cystic duct obstruction, thereby complicating early-stage diagnosis. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Chronic osteomyelitis of ribs 
• Metastatic carcinoma 
• Infected epidermal inclusion cyst 
• Discharging tuberculoma 
• Pyogenic granuloma 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment strategy for cholecystocutaneous fistula involves a thorough plan targeting the root cause and managing associated symptoms. Here is an overview of the treatment steps: 

Medical Stabilization: 

Initiate by stabilizing the patient’s medical condition. Employ analgesics, antibiotics, and supportive care to address symptoms such as pain, fever, and infection. 

Imaging Studies and Diagnosis Confirmation: 

Confirm the diagnosis through imaging studies like computed tomography (CT), ultrasound, or MRI (magnetic resonance imaging). These investigations help determine the extent of the fistula and associated abnormalities. 

Nutritional Support: 

Assess and provide nutritional support based on the patient’s nutritional status and any dietary restrictions. In some instances, nutritional supplements may be necessary. 

Surgical Intervention: 

Conduct surgical removal of the cholecystocutaneous fistula as the cornerstone of treatment. The surgical procedure may involve: 

• Excising the fistula tract. 
• Closing the connection between the gallbladder and the skin. 
• Potentially removing the gallbladder itself (cholecystectomy). 

Reconstruction of the biliary and digestive tracts may be performed to restore normal flow, with the specific procedure contingent upon the extent of the fistula and associated conditions. 

Complications Management: 

Complications, if any, that may arise during or after surgery, such as strictures, infections, or other abnormalities, should be identified and addressed. Timely intervention is crucial to prevent further complications. 

Postoperative Care: 

Closely monitor the patient in the postoperative phase for signs of complications, ensuring effective pain management. Nutritional support may continue, and dietary adjustments may be recommended based on the performed surgical procedure. 

Long-Term Follow-Up: 

Establish a routine of regular follow-up appointments to track the patient’s recovery, assess for any recurrence of cysts or complications, and address any concerns or symptoms. 

Individualized Approach: 

Customize the treatment plan based on the patient’s age, overall health, and specific attributes of the cholecystocutaneous fistula. Consider any underlying gallbladder diseases or contributing factors. 

Patient Education: 

Deliver comprehensive education to the patient regarding the condition, treatment plan, and postoperative care. Encourage adherence to medical recommendations and lifestyle modifications. 

Multidisciplinary Collaboration: 

Engage in collaborative efforts with a multidisciplinary team, including gastroenterologists, surgeons, radiologists, and other specialists. This ensures a comprehensive and well-coordinated approach to treatment. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

lifestyle-modification-of-cholecystocutaneous-fistula

Modifying one’s lifestyle to manage cholecystocutaneous fistula involves embracing changes that promote overall well-being and contribute to condition management.

Although these adjustments may not directly treat the fistula, they play a role in fostering a better lifestyle and potentially reducing the risk of complications. Below are recommended lifestyle modifications: 

Dietary Adjustments: 

Adopt a Low-Fat Diet: Decrease the consumption of high-fat foods, as they can stimulate bile production and potentially worsen symptoms. 

Opt for Small, Frequent Meals: Choose smaller, more frequent meals to facilitate the digestive process and minimize stress on the biliary system. 

Hydration: 

Ensure Adequate Hydration: Maintain proper fluid balance to support overall health. 

Avoidance of Trigger Foods: 

Identify and Steer Clear of Trigger Foods: Recognize and avoid foods that may induce symptoms or discomfort. Keeping a food diary can assist in pinpointing specific triggers. 

Weight Management: 

Sustain a Healthy Weight: A balanced diet and frequent exercise will help you reach and stay at a healthy weight. Being overweight might aggravate gallbladder problems. 

Regular Exercise: 

Engage in Consistent Physical Activity: Participate in regular exercise to promote digestive health and weight management. However, consult with healthcare providers before initiating any new exercise regimen. 

Stress Management: 

Practice Stress-Reduction Techniques: Incorporate stress-reducing practices such as mindfulness, meditation, or yoga, as stress can potentially impact digestive health. 

Regular Follow-Up Appointments: 

Adhere to Scheduled Follow-Up Appointments: Comply with scheduled appointments with healthcare providers to monitor recovery, assess for complications, and address any concerns. 

Medication Adherence: 

Follow Medication Recommendations: If prescribed medications for pain management or symptom relief, adhere to the recommended dosage and schedule. 

Smoking Cessation: 

Quit Smoking: If applicable, cease smoking, as smoking is associated with various health issues, and quitting can positively impact overall health. 

Limit Alcohol Intake: 

Moderate Alcohol Consumption: Exercise moderation in alcohol intake, as excessive alcohol consumption can negatively affect the liver and gallbladder. 

Hygienic Practices: 

Maintain Good Hygiene: Ensure proper hygiene around the fistula site to prevent infections. Adhere to healthcare provider instructions for wound care. 

Use of analgesics in the treatment of cholecystocutaneous fistula

The primary strategy for addressing cholecystocutaneous fistula involves surgical intervention, with medications assuming a supportive role.

Medications may be recommended to relieve symptoms, prevent infections, or address specific issues associated with the condition. It’s essential to underscore that the use of medications is personalized to each case, and the specific drugs prescribed can vary depending on the individual needs and circumstances of the patient.

The following are some medications that could be contemplated in the management of cholecystocutaneous fistula: 

Acetaminophen: It is an anti-inflammatory drug which is a derivative of anilide. It is used as an analgesic in the management of pain in patients with cholecystocutaneous fistula. 

It is aimed at alleviating pain and may be suggested to manage pain linked to the fistula or to alleviate discomfort postoperatively. 

Use of antibiotics in the treatment of cholecystocutaneous fistula

In instances where there is a potential risk of infection or if signs of infection are evident, antibiotics may be prescribed. The choice of antibiotics will be determined by the type of infection and microbial sensitivity. 

Piperacillin/Tazobactam: Penicillins and beta-lactamase inhibitors are a class of antibiotics that includes piperacillin and tazobactam. This combo injection is used to treat post-operative wounds as well as bacterial infections in a variety of body areas, including the skin, lungs, female reproductive organs, stomach, and intestines. 

Nutritional plan for cholecystocutaneous fistula

Based on the specific surgical procedure and the nutritional status of the patient, healthcare providers may propose nutritional supplements to support the recovery process. This becomes particularly pertinent when concerns arise regarding malnutrition or when the patient faces difficulties in maintaining a balanced diet. 

surgical-intervention-in-the-management-of-cholecystocutaneous-fistula

The improper connection between the gallbladder and the skin is addressed by a surgical method customized to each individual case, which is a crucial part of the care of cholecystocutaneous fistula. The essential elements of surgical intervention for cholecystocutaneous fistula comprise: 

Excision of Fistula Tract: 

• The surgical procedure initiates with the removal of the fistula tract, a foundational step involving the excision of the abnormal connection between the gallbladder and the skin to eliminate the path of communication. 

Closure of Connection: 

• The surgical team undertakes the closure of the connection between the gallbladder and the skin, a critical measure aimed at preventing further leakage of bile or other fluids. This closure is imperative for the restoration of normal anatomical integrity. 

Cholecystectomy (if necessary): 

• Depending on the extent of the fistula and associated gallbladder conditions, the surgical team may opt for the removal of the gallbladder itself (cholecystectomy) when deemed necessary to forestall recurrence or complications. 

Reconstruction of Biliary and Digestive Tracts: 

• When deemed essential, the surgical procedure involves the reconstruction of the biliary and digestive tracts to restore normal flow. This may entail reconnecting the bile duct to the small intestine (hepaticojejunostomy) to ensure proper drainage. 

Management of Complications: 

• The surgical team diligently identifies and addresses any complications that may arise during the procedure or in the postoperative period. This comprehensive approach includes prompt intervention for infections, strictures, or other abnormalities. 

Postoperative Care: 

• Following surgery, patients undergo close monitoring for signs of complications, and the provision of adequate pain management is ensured. Nutritional support may persist based on the surgical procedure, with potential dietary adjustments being recommended. 

Long-Term Follow-Up: 

• Regular follow-up appointments are scheduled to oversee the patient’s recovery, assess for any recurrence of cysts or complications, and attend to any emerging concerns or symptoms. This long-term monitoring is vital for ensuring sustained well-being. 

phases-of-management-in-cholecystocutaneous-fistula

The management of cholecystocutaneous fistula encompasses various phases, each contributing to a comprehensive and effective approach. The essential phases in the management of cholecystocutaneous fistula are delineated below: 

Diagnostic Evaluation: 

This initial phase concentrates on accurately diagnosing the cholecystocutaneous fistula. Diagnostic tools such as imaging studies (ultrasound, CT, MRI) and clinical assessments aid in confirming the presence of an abnormal connection between the gallbladder and the skin. 

Medical Stabilization: 

Upon diagnosis, the management commences with stabilizing the patient’s medical condition. Priorities in this phase include providing symptomatic relief, managing pain, and addressing any signs of infection. Medications, including analgesics and antibiotics, may be prescribed. 

Surgical Intervention: 

The crux of treatment involves surgical intervention to rectify the cholecystocutaneous fistula. The surgical procedure comprises the excision of the fistula tract, closure of the connection between the gallbladder and the skin, and, if necessary, cholecystectomy (removal of the gallbladder). Reconstruction of the biliary and digestive tracts may also be undertaken. 

Complications Management: 

The surgical team vigilantly monitors and manages any complications that may arise during or after the surgical intervention. This encompasses addressing infections, strictures, or other abnormalities promptly to prevent further complications. 

Postoperative Care: 

Following surgery, meticulous postoperative monitoring is indispensable. This phase involves observing the patient for signs of complications, ensuring adequate pain management, and providing nutritional support based on the surgical procedure. Dietary adjustments may be recommended. 

Long-Term Follow-Up: 

The patient is booked for follow-up appointments on a regular basis to track their healing over time. This phase involves assessing for any recurrence of cysts or complications, addressing emerging concerns or symptoms, and ensuring the patient’s overall well-being. 

Individualized Approach: 

Throughout the management process, an individualized approach is pivotal. Tailoring the treatment plan based on the patient’s age, overall health, and specific characteristics of the cholecystocutaneous fistula ensures personalized and effective care. 

Patient Education: 

Patient education is an ongoing process, furnishing comprehensive information about the condition, treatment plan, and postoperative care. Encouraging adherence to medical recommendations and lifestyle modifications is an integral aspect. 

Multidisciplinary Collaboration: 

Collaboration with a multidisciplinary team, including gastroenterologists, surgeons, radiologists, and other specialists, ensures a holistic and well-coordinated approach to treatment throughout all phases. 

Medication

Future Trends

Media Gallary

References

Cholecystocutaneous Fistula – StatPearls – NCBI Bookshelf (nih.gov)