The Internal Biliary Fistula--reappraisal of Incidence, Type, Diagnosis and Management of 33 Consecutive Cases

To reevaluate the current features of spontaneous internal biliary fistulas, we reviewed 1,929 consecutive patients who had been treated for biliary tract diseases during the recent 12-year period. Thirty-three patients had internal biliary fistulas and the incidence was 1.9%. Of 33 patients, 20 were women and 13 were men with the average age 63 years, and their mean duration of illness was 4 years. A total of 37 fistulas were found and the most common type was choledochoduodenal (62%), followed by cholecystoduodenal (19%), cholecystocholedochal (11%) and cholecystocolonic (8%) fistulas. Internal biliary fistulas of thirty-one patients were caused by biliary stones and those of two patients by malignant tumors. All of the 17 bile samples examined were bacteria positive and the majority of calculi were brown pigment stones. All of the choledochoduodenal fistulas were correctly diagnosed by endoscopic retrograde cholangiography. In 14 patients with cholecystoenteric or cholecystocholedochal fistulas, direct evidence of the internal fistula was obtained only in 7 patients (50%) preoperatively. Pneumobilia, a small atrophic gallbladder adherent to the neighboring organs and a history of spontaneous disappearance of jaundice in elderly patients may indicate the presence of a cholecystoentric fistula. Since the preoperative diagnostic rate for internal biliary fistula involving the gallbladder is still low, care is necessary before and at the time of surgery especially during laparoscopic cholecystectomy for elderly patients with cholelithiasis.