A 53-year-old man presented with a 3-year history of recurrent abdominal pain localised to the upper abdomen. The pain was moderate in intensity and occurred on an empty stomach. It was relieved with food intake. There was no associated nausea or vomiting. There was no history of associated co-morbidities. Since the symptoms were suggestive of APD, an oesophagogastroduodenoscopy was performed, which found an ulcer in the first part of the duodenum (Fig 1). A diagnosis of a duodenal ulcer was made and he was given two-week course of Helicobacter pylori eradication therapy with omeprazole, clarithromycin and amoxicillin. 
As there was no improvement in symptoms following treatment, ultrasonography of the abdomen was performed to look for other causes. This revealed pneumobilia with a 2.2cm x 1.9cm well defined hypoechoic lesion close to the proximal body of the pancreas, suggestive of a peripancreatic lymph node, and a 1cm x 0.9cm non-shadowing echogenic focus in the gallbladder, suggestive of sludge. Pneumobilia was also demonstrated on plain x-ray of the abdomen (Fig 1). An upper gastrointestinal contrast study was carried out to diagnose the aetiology, which revealed a CDF. A repeat oesophagogastroduodenoscopy was performed and the fistula was clearly made out (Fig 1).
Based on these findings, a provisional diagnosis of chronic duodenal ulcer with CDF with chronic cholecystitis was considered and the patient underwent open cholecystectomy and truncal vagotomy with gastrojejunostomy. Intraoperatively, a nodule with a 1cm x 1.5cm fistulous opening was found in the duodenum, with multiple peritoneal deposits. The possibility of TB was considered. On histopathology, the gallbladder showed chronic cholecystitis with intestinal metaplasia and the peritoneal nodules revealed caseation with epitheloid granulomas suggestive of TB (Fig 2). 
Postoperatively, the patient was investigated for other foci of TB and retropositive status, both of which were negative. He was put on Revised National Tuberculosis Control Program category I antitubercular therapy with isoniazid, rifampicin, ethambutol and pyrazinamide for two months, followed by isoniazid and rifampicin for four months. He has been on regular follow-up for the past three years and remains asymptomatic.