Spontaneous cholecysto-cutaneous fistula in a patient with peritoneal carcinomatosis

Case report

We report the case of a 62-year-old male with a history of a neuroendocrine tumor of the small bowel diagnosed in 2019, with peritoneal and hepatic progression in 2023 despite oncologic treatment.

He presented at the emergency room with a two-week history of a right upper quadrant mass (Fig. 1A) and mild hepatobiliary profile alterations (bilirubin 0.50 mg/dL, AST 25 U/L, ALT 27 U/L, alkaline phosphatase 179 U/L, GGT 136 U/L), without clinical or laboratory signs of infection. Imaging findings were inconclusive, suggesting either a newly developed peritoneal implant or a perivesicular abscess (Fig. 1B). Empirical antibiotic therapy was started with ciprofloxacin and metronidazole, and a histological sample revealed firm, non-purulent tissue. While waiting for the results, the lesion spontaneously fistulized, releasing purulent material. After an incision was performed, gallstones were expelled (Fig. 2). Enterococcus faecium was isolated in microbiological cultures. Two days later, an open cholecystectomy and fistulectomy were conducted, with a favorable outcome. Histological analysis ruled out malignancy.

Figure 1.

(A) Painful, erythematous mass in the right upper quadrant. (B) Axial contrast-enhanced computed tomography (CT) scan showing an irregular perihepatic collection extending into the subcutaneous tissue, as indicated by the white arrow.

Figure 2.

Spontaneous cholecysto-cutaneous fistula with purulent discharge and extrusion of gallstones after surgical incision.

Cholecysto-cutaneous fistula is an uncommon biliary complication, typically resulting from surgery, trauma, or complex chronic cholecystitis.^1,2 Less than 25 cases have been documented in the literature in the past few decades.³ The differential diagnosis in oncologic patients can be challenging, as atypical presentations may initially suggest disease progression rather than a treatable condition. This case emphasizes the significance of maintaining a high level of suspicion and using a multidisciplinary approach to achieve timely diagnosis and appropriate management.

CRediT authorship contribution statement

Conception and design: Miriam Bragado Pascual and Rosanna Villanueva Hernández.

Manuscript writing: Miriam Bragado Pascual and Rosanna Villanueva Hernández.

Administrative support: Rosanna Villanueva Hernández.

Collection and assembly of data: Miriam Bragado Pascual and Rosanna Villanueva Hernández.

Data analysis and interpretation: All authors.

Accountable for all aspects of the work: All authors.

Ethical approval

Compliance with internationally recognized ethical standards and ethical protocols of the site where the study was conducted. The patient has given written informed consent for publication (including the publication of images).

Funding

No funding has been received for the completion of this study.

Conflict of interest

The authors have no conflicts of interest to declare.