Introduction

Cholecystocutaneous fistula (CCF) is characterized by an abnormal communication between the gallbladder and the skin [1]. Fewer than 100 cases of cholecystocutaneous fistula have been documented in the medical literature [2]. Gallstone disease remains the most common underlying cause of CCF, with repeated episodes of gallbladder inflammation, contributing to fistula formation [3]. The pathophysiological process usually involves progressive gallbladder inflamation, vascular compromise, tissue necrosis, and eventual perforation of the gallbladder wall. Because of its relatively poor blood supply, the fundus is considered the most common site of gallbladder perforation [4]. Perforation of the gallbladder wall results in abscess formation with extension into the anterior abdominal wall and subsequent fistula formation [6].

Case Presentation

A 62-year-old male with a history of hypertension, type 2 diabetes mellitus, dyslipidemia, cardiac arrhythmia, a recent cardiac stent placement, and past surgical history of bilateral inguinal hernia repair. Patient presented, to the gastroenterologist, with a two-day history of mild epigastric and right upper quadrant abdominal pain. No fever, chills or jaundice.

Initial laboratory investigations showed elevated transaminases with ALT of 95 U/L, AST of 88 U/L, alkaline phosphatase of 160 U/L and gamma-glutamyl transferase (GGT) is 110 U/L. Total and direct bilirubin levels remained within normal limits.

Abdominal ultrasonography revealed a large gallstone measuring approximately 3 cm occupying most of the gallbladder body, with mild gallbladder wall thickening measuring less than 5 mm. No biliary duct dilatation was identified. Although cholecystectomy was indicated, surgical intervention was deferred because the patient had recently sustained a myocardial infarction and undergone coronary stent placement.

Discussion

CCF may develop spontaneously as a complication of neglected gallbladder, following interventions after percutaneous cholecystostomy tube removal, or in association with gallbladder carcinoma [2]. Patients typically present with a localized inflammatory swelling, recurrent abdominal wall abscess, or a chronic discharging sinus, most frequently involving the right upper quadrant [7].

The pathophysiology of CCF in this patient is consistent with the classically described sequence of events. Chronic gallstone disease, with repeated episodes of inflammation, promotes progressive gallbladder distension, increased intraluminal pressure, vascular compromise, and eventual mural necrosis and perforation [3,4]. Once perforation occurs, and is contained by surrounding adhesions, the inflammatory process may track through the anterior abdominal wall, causing collection and eventually abscess that will drain through the skin [4,6]. The second etiology is when there are repeated episodes of cholecystitis, in an unfit patient for surgery, and a decision is made to insert a                 percutaneous cholecystostomy tube. 

Sometimes after    removal of    the cholecystostomy tube, the tract persists forming cholecystocutanous fistula if there is distal obstruction [5]. In malignant gallbladder disease, rarely the tumor progressively invades the abdominal wall. After that, the gallbladder may either drain into the peritoneal cavity or become adherent to adjacent structures, including the anterior abdominal wall forming an abscess that may drain to the skin forming a fistula [10].

The persistent discharge for over 2 months, despite treatment with ciprofloxacin, and the persistent culture result of Pseudomonas aeruginosa, even after drainage, raised the suspicion of a communicating fistula. The rarity of CCF frequently results in initial misdiagnosis, with many patients managed for presumed superficial soft-tissue or abdominal wall infections before the true biliary etiology is recognized [8].

The cornerstone of management for CCF remains definitive surgical treatment consisting of cholecystectomy with complete excision of the fistulous tract [9]. Although minimally invasive, fully laparoscopic approaches have been described, severe chronic inflammation and distorted anatomy may necessitate conversion to an open procedure.

Conclusion

This case highlights several important lessons. First, CCF should be considered in any patient with longstanding gallstone disease who presents with a chronic abdominal wall abscess or discharging sinus, particularly when definitive cholecystectomy has been delayed. Second, prompt recognition with appropriate imaging, including fistulography—is essential to avoid misdiagnosis and unnecessary delays. Third, while laparoscopic management may be attempted, surgeons should maintain a low threshold for conversion to an open approach when dense inflammation precludes safe dissection. Definitive treatment with cholecystectomy and complete fistula excision remains the gold standard and was associated with an excellent outcome in our patient.

Reference

1. Khan A, Beckley I, Dobbins B, Rogawski KM. Spontaneous cholecystocutaneous fistula, a rare complication of gallstone disease: case report and literature review. J Surg Case Rep. 2011;2011(3):3. doi:10.1093/jscr/2011.3.3.
2. Alsaman MZB, Mazketly M, Ziadeh M, Aleter O, Ghazal A. Cholecystocutaneous fistula incidence, etiology, clinical manifestations, diagnosis and treatment: A literature review. Ann Med Surg (Lond). 2020;59:180-185. doi:10.1016/j.amsu.2020.09.035.
3. Kumar SS, Kumar A, Coelho R, et al. Spontaneous cholecystocutaneous fistula: a rare presentation of gallstones. BMJ Case Rep. 2013;2013:bcr2013009267. doi:10.1136/bcr-2013-009267.
4. Niemeier OW. Acute free perforation of the gall-bladder. Ann Surg. 1934;99(6):922-9