Effect of Gallbladder Disease on the Duodenocolic Relationships

The nonspecificity of signs and symptoms of diseases of the gallbladder often makes a clinical diagnosis difficult. At times, it is the striking manifestation of the secondary effects on the neighboring bowel that first brings the patient to medical attention.

Inflammatory adhesions may develop between the gallbladder and the postapical duodenum, permitting the development of fistulous communication (Fig. 1019).

The gallbladder is closely applied to the superior as pect of the anterior hepatic flexure in most individuals (Fig. 10-20). The distance between the inner walls of the gallbladder and the adjacent colon is normally less than 1.5 cm.

When the gallbladder enlarges, as in acute cholecystitis, hydrops, empyema, or Courvoisier's sign of pan-creaticoduodenal malignancy, plain films or barium enema study may reveal smooth extrinsic compression of the hepatic flexure (Figs. 10-21 and 10-22). Accompanying pericholecystitis or marked fibrous adhesions may result in mucosal edema or fixation (Fig. 10-23). The postapical duodenum is characteristically displaced text continues on page 556

Empyema Gall Bladder

Fig. 10—14. Duodenocolic fistula secondary to granulomatous colitis.

Upper GI series demonstrates fistulous communication (arrow) from the infraampullary portion of the descending duodenum to the hepatic flexure, with premature opacification of the transverse colon. Crohn's disease of the large intestine is apparent.

Fig. 10—14. Duodenocolic fistula secondary to granulomatous colitis.

Upper GI series demonstrates fistulous communication (arrow) from the infraampullary portion of the descending duodenum to the hepatic flexure, with premature opacification of the transverse colon. Crohn's disease of the large intestine is apparent.

Crohn Fistula

Fig. 10—15. Duodenocolic fistula secondary to granulomatous colitis.

(a and b) Upper GI series demonstrates wide communication (arrows) between the third portion of the duodenum and the transverse colon, which is involved by Crohn's disease. The partially bypassed small intestinal loops show changes of malabsorption.

Fig. 10—15. Duodenocolic fistula secondary to granulomatous colitis.

(a and b) Upper GI series demonstrates wide communication (arrows) between the third portion of the duodenum and the transverse colon, which is involved by Crohn's disease. The partially bypassed small intestinal loops show changes of malabsorption.

Fistula Between Gallbladder And Duodenum

Fig. 10-16. Duodenocolic fistula secondary to granulomatous colitis.

Barium enema (a) and upper GI series (b) demonstrate fistulas between the hepatic flexure of the colon and the duodenum and between the transverse colon and the greater curvature of the stomach (arrows). Extensive Crohn's disease of the large intestine is evident.

Fig. 10-16. Duodenocolic fistula secondary to granulomatous colitis.

Barium enema (a) and upper GI series (b) demonstrate fistulas between the hepatic flexure of the colon and the duodenum and between the transverse colon and the greater curvature of the stomach (arrows). Extensive Crohn's disease of the large intestine is evident.

Fibrotic Gallbladder

Fig. 10—17. Duodenocolic fistula secondary to intestinal tuberculosis.

(a) Barium enema demonstrates fistulization to the duodenum (D) from the colon, which has multiple areas of stricture with severe adhesions. The colonic wall is fibrotic and thin.

(b) CT clearly documents the duodenocolic fistula (arrow). (Reproduced from Ha et al.17)

Fig. 10—17. Duodenocolic fistula secondary to intestinal tuberculosis.

(a) Barium enema demonstrates fistulization to the duodenum (D) from the colon, which has multiple areas of stricture with severe adhesions. The colonic wall is fibrotic and thin.

(b) CT clearly documents the duodenocolic fistula (arrow). (Reproduced from Ha et al.17)

Intestinal Fistulization

Fig. 10—18. Duodenocolic fistula from chronic "blowout" of duodenal bulb.

Following a Billroth II gastrojejunostomy, a fistulous communication (arrow) has developed between the sewn-over duodenal bulb and the hepatic flexure of the colon.

Fig. 10—19. Cholecystoduodenal fistula with gallstone ileus.

(a) Upper GI series demonstrates tract (curved arrow) between the duodenum and gallbladder. A large gallstone is impacted in a proximal jejunal loop (arrows).

(b) CT shows inflammatory changes (arrow) between the duodenum (D) and the shrunken gallbladder (GB), which contains air. A dilated loop ofjejunum (J) is evident. P = pancreas.

(c) At a lower level, the partially calcified cholesterol gallstone within the obstructed loop is documented (arrow).

Fig. 10—19. Cholecystoduodenal fistula with gallstone ileus.

(a) Upper GI series demonstrates tract (curved arrow) between the duodenum and gallbladder. A large gallstone is impacted in a proximal jejunal loop (arrows).

(b) CT shows inflammatory changes (arrow) between the duodenum (D) and the shrunken gallbladder (GB), which contains air. A dilated loop ofjejunum (J) is evident. P = pancreas.

(c) At a lower level, the partially calcified cholesterol gallstone within the obstructed loop is documented (arrow).

Hepatic Flexure Syndrome

Fig. 10—20. Right parasagittal section, showing the close relationship of the gallbladder (GB) to the anterior hepatic flexure of the colon (C). L = liver; RK = right kidney.

Duodenocolic Fistula

Fig. 10—21. Impression of adherent "porcelain" gallbladder.

(a) Plain film shows large calcified gallbladder with impacted stone in its neck (arrow).

(b) Barium enema study demonstrates displacement of gallbladder (black arrows) and impression upon anterior hepatic flexure to which it is adherent. White arrow shows impacted stone.

(Reproduced from Ghahremani and Meyers.19)

Fig. 10—21. Impression of adherent "porcelain" gallbladder.

(a) Plain film shows large calcified gallbladder with impacted stone in its neck (arrow).

(b) Barium enema study demonstrates displacement of gallbladder (black arrows) and impression upon anterior hepatic flexure to which it is adherent. White arrow shows impacted stone.

(Reproduced from Ghahremani and Meyers.19)

Edema Anterior Gallbladder

Fig. 10—22. Acute cholecystitis.

(a) Mass impression on superior aspect of anterior hepatic flexure, with mucosal irregularities.

(b) Medial displacement and spasm of proximal descending duodenum. (Reproduced from Ghahremani and Meyers.19)

Fig. 10—22. Acute cholecystitis.

(a) Mass impression on superior aspect of anterior hepatic flexure, with mucosal irregularities.

(b) Medial displacement and spasm of proximal descending duodenum. (Reproduced from Ghahremani and Meyers.19)

Gallbladder Hydrops

Fig. 10—23. Acute acalculous cholecystitis.

The inflammatory process of the gallbladder (GB) produces intramural edema within the superior aspect of the anterior hepatic flexure of the colon (arrow).

medially and may show features of spasm, luminal narrowing, and mucosal irregularities. Carcinoma of the gallbladder commonly infiltrates all layers of its wall and rapidly extends into the surrounding structures. As many as 15% show evidence of colonic invasion on barium enema studies (Fig. 10-24). CT readily illustrates invasion of the colon (Fig. 10-25a) or duodenum (Fig. 10-25b). Fistulous communication between the duodenum and colon may occur from acute cholecystitis or carcinoma of the gallbladder22,23 (Figs. 10-26 through 10-32).

text continues on page 560

Gallbladder Carcinoma

Fig. 10-24. Carcinoma of the gallbladder.

(a) Fixation of mucosal folds of anterior hepatic flexure.

(b) Marked compression, narrowing, and medial displacement of the proximal descending duodenum. (Reproduced from Ghahremani and Meyers.19)

Fig. 10-24. Carcinoma of the gallbladder.

(a) Fixation of mucosal folds of anterior hepatic flexure.

(b) Marked compression, narrowing, and medial displacement of the proximal descending duodenum. (Reproduced from Ghahremani and Meyers.19)

Gallbladder Disease Nursing

Fig. 10-25. Gallbladder carcinoma invading the colon (a) and duodenum (b) in two different cases.

(a) CT demonstrates irregular thickening of the gallbladder wall (black arrow) and direct extension to the hepatic flexure of the colon (white arrows). (Reproduced from Ohtani et al.20)

(b) CT shows an intraluminal mass of the gallbladder extending into the hepatic parenchyma (arrows). Contrast enhancement of the lateral wall of the descending duodenum (arrowheads) indicates direct invasion. (Reproduced from Ohtani et al.21)

Fig. 10-25. Gallbladder carcinoma invading the colon (a) and duodenum (b) in two different cases.

(a) CT demonstrates irregular thickening of the gallbladder wall (black arrow) and direct extension to the hepatic flexure of the colon (white arrows). (Reproduced from Ohtani et al.20)

(b) CT shows an intraluminal mass of the gallbladder extending into the hepatic parenchyma (arrows). Contrast enhancement of the lateral wall of the descending duodenum (arrowheads) indicates direct invasion. (Reproduced from Ohtani et al.21)

Fig. 10—26. Cholecystoduodenal fistula secondary to chronic cholecystitis.

Enhanced CT demonstrates a narrow fistula (small arrow) between the contracted gallbladder (black arrow) and the duodenum (white arrow). (Reproduced from Shimono et al.23)

Cholesterol Gall Stones

Fig. 10-27. Cholecystoduodenal fistula.

Enhanced CT shows air-fluid levels in the contracted gallbladder (black arrow), the result of a fistula from the duodenum (white arrow). (Reproduced from Shomono et al.23)

Cholecystoduodenal Fistula

Fig. 10-28. Cholecystocolic fistula secondary to chronic cholecystitis.

(a) Frontal and (b) oblique views during a barium enema study demonstrate communication between the anterior hepatic flexure and a small deformed gallbladder.

Fig. 10-28. Cholecystocolic fistula secondary to chronic cholecystitis.

(a) Frontal and (b) oblique views during a barium enema study demonstrate communication between the anterior hepatic flexure and a small deformed gallbladder.

Duodenocolic Fistula

Fig. 10—29. Cholecystocolic fistula.

Enhanced CT demonstrates a narrow fistula (small arrow) between the gallbladder (black arrow) and the colon (white arrow).

(Reproduced from Shimono et al.23)

Rectovaginal Fistula Barium Enema

Fig. 10—30. Cholecystocolic fistula complicating chronic cholecystitis in two patients.

(a) Barium enema study demonstrates a wide communication between the fundus of the gallbladder containing stones and the adherent hepatic flexure.

(b) Gallstone ileus due to impaction of large nonopaque gallstones (large arrows) in the sigmoid colon with distended intestinal loops proximally. The Cholecystocolic fistula and the shrunken gallbladder (small arrow) are partially opacified with barium.

(Reproduced from Ghahremani and Meyers.19)

Fig. 10—30. Cholecystocolic fistula complicating chronic cholecystitis in two patients.

(a) Barium enema study demonstrates a wide communication between the fundus of the gallbladder containing stones and the adherent hepatic flexure.

(b) Gallstone ileus due to impaction of large nonopaque gallstones (large arrows) in the sigmoid colon with distended intestinal loops proximally. The Cholecystocolic fistula and the shrunken gallbladder (small arrow) are partially opacified with barium.

(Reproduced from Ghahremani and Meyers.19)

Fig. 10—31. Cholecystocolic fistula secondary to carcinoma of the gallbladder.

Barium enema study demonstrates the malignancy infiltrating the anterior hepatic flexure and projecting within the partially opacified gallbladder lumen (arrows)

Rectovaginal Fistula Barium Enema

Fig. 10—32. Carcinoma of the gallbladder with duodenocolic fistula.

Upper GI series demonstrates the communication to the hepatic flexure of the colon across the malignant bed of the gallbladder

(Reproduced from Ghahremani and Meyers.19)

Fig. 10—32. Carcinoma of the gallbladder with duodenocolic fistula.

Upper GI series demonstrates the communication to the hepatic flexure of the colon across the malignant bed of the gallbladder

(Reproduced from Ghahremani and Meyers.19)

Hepatic Flexure Diverticulitis
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