WHEN NATURE TRIES TO FIND ITS WAY: AN UNUSUAL CASE OF CHOLEDOCHO-DUODENAL FISTULA COMPLICATING A “DIFFICULT” CHOLEDOCHOLITHIASIS

During ERCP for choledocholitiasis, we found a bulging near the major papilla, with an orifice draining bile, suspected for biliary fistula. Contrast-medium injection through the orifice showed a stone impacted behind the duodenal wall, in a false lumen communicating with CBD by fistulous tract; CBD was occupied by multiple large stones.

After precutting the sclerotic and “uninhabited” papilla, CBD cannulation confirmed “difficult” choledocholithiasis with fistula in the distal tract. Using DASE technique, complete CBD toilette with balloon was made. Fistulous orifice was enlarged using a cutting needle, with expulsion of the stone impacted. Cutting gap was repaired positioning two endoclips.