The unusual suspect: Cholecystocutaneous fistulas mimicking bile leak
70-year-old female with history of bowel surgery and revised ostomy presented with abdominal pain and bacteremia. Gallbladder was not visualized on right upper quadrant ultrasound. Subsequently, HIDA scan was done which failed to show filling of gallbladder and contrast accumulation in right lower quadrant of abdomen, suggesting bile leak. Computed Tomography (CT) of abdomen/pelvis in conjunction with hepatobiliary scan raised suspicion for gall bladder perforation. CT also showed subcutaneous fluid collection which was initially overlooked. Later, fistulogram of the cutaneous fistula in right abdomen showed contrast opacification of the gallbladder and biliary tree consistent with cholecystocutaneous fistulas. IMAGING FINDINGS: HIDA scan showed tubular activity localized to the right with accumulation of radiotracer in the right lower quadrant. CT abdomen with IV and PO contrast shows elongated gallbladder extending inferolaterally to the right lower abdomen and subcutaneous fluid collection. Contrast injection in the fistula via catheter shows contrast opacification of fistula connecting to the elongated gallbladder. Subsequently, opacification of the cystic and biliary ducts is noted. Small, oval filling defect is seen in the cystic duct consistent with gall stone. Discussion: A few case reports describe development of spontaneous cholecystocutaneous fistula. Many of these patients have underlying chronic gall bladder disease, whereas some are related to prior surgery.