their occurrence was first described in 1670 by thilesus . however , at that time fistulas were a common complication of chronic and untreated cholecystitis . according to a 2005 study , 226 cases have been reported in total , with fewer than 25 in the last 50 years .
the reduced incidence in current times can be attributed to more rapid diagnosis and treatment with antibiotics or surgery .
although occurring in acalculous cholecystitis and carcinoma of the gallbladder , fistulas are still most commonly associated with gallstones [ 3 , 4 ] .
obstruction of the cystic duct leads to an increase in gallbladder pressure and reduced perfusion with necrosis , which consequently causes gallbladder perforation .
the contents of the gallbladder may then empty into the peritoneal cavity and an abscess may form or a fistula may develop through adherence to the duodenum , colon or abdominal wall , often via the fundus of the gallbladder . the right upper quadrant is the most common location for the exit tract of the fistula , but locations such as the gluteal region , umbilicus and right groin have also been documented .
cholecystocutaneous fistulas are most often seen in elderly women over the age of 60 , likely due to coexistent disease and non - specific symptoms interfering with diagnosis .
a white 85-year - old female with hypertension and a previous history of breast biopsy underwent endoscopic retrograde cholangiopancreatography with sphincterotomy after initially presenting on may 3 , 2011 with common duct stones .
the patient was initially seen in the emergency department complaining of a 3-day history of sharp intermittent epigastric and right upper quadrant pain radiating to the central back .
mild scleral icterus was noted , but there were no signs of jaundice or lymphadenopathy .
her abdomen was soft , non - distended and mildly tender to palpation with a positive murphy 's sign .
routine blood work demonstrated an elevated white blood cell count of 16.1 , no abnormalities on sma7 , elevated lipase > 3,000 , and elevated liver function testing including an alkaline phosphatase of 215 , a bilirubin of 41 , an ast of 100 , a ggt of 305 and an alt of 194 .
clinical evidence of mild jaundice accompanied by blood work abnormalities and positive radiological signs led to the diagnosis of acute calculous cholecystitis , common bile duct stones up to 7 mm in size and biliary gallstone pancreatitis .
she was treated conservatively with intravenous antibiotics and underwent endoscopic retrograde cholangiopancreatography with sphincterotomy for removal of several stones of various sizes .
percutaneous cholecystostomy was then carried out for drainage of the gallbladder after development and medical control of atrial fibrillation .
on june 1 , 2011 she was re - admitted to the hospital with a left lower lobe pulmonary embolism .
on june 27 , 2011 the percutaneous drain was removed at her request . in early august 2011 ,
she re - developed right upper quadrant discomfort ; furthermore , she noted some purulent drainage from the percutaneous drain site and extrusion of approximately 30 gallstones .
she had several follow - up ultrasounds which identified a fistulous tract measuring 0.78 cm in diameter communicating with the external opening in the right upper quadrant ( fig .
an irregular hypoechoic area just inside the subcutaneous tissue measuring 4.1  2.7 cm was presumed to represent a contracted gallbladder .
plans were made for laparoscopic cholecystectomy and management of her cholecystocutaneous fistula on february 22 , 2012 , once she finished her coumadin regiment . in the morning of the operation , on february 22 , 2012
, the patient 's inr was still elevated at 1.8 and the surgery was re - scheduled for a month later .
on april 18 , 2012 the patient underwent laparoscopic cholecystectomy and fistula division ( fig .
2 ) . three additional gallstones were found in the gallbladder at the time of the operation .
we present the case of an 85-year - old white female who was diagnosed with a cholecystocutaneous fistula that developed as a complication following removal of a percutaneous drain that was used to treat her acute cholecystitis .
re - occurrence of her cholecystitis after drain removal and the presence of gallstones promoted the production of a fistula along the pre - existing tract of the drain . her concurrent treatment with anticoagulants for a pulmonary embolism delayed the definitive management of her cholecystitis and fistula .
fortunately , the patient remained in reasonably good health throughout the waiting period from time of fistula diagnosis to surgery .
more conservative approaches such as percutaneous cholecystotomy have been used in high - risk patients , leading to spontaneous closure of the fistula . however , in this case the fistula developed through the old drain tract , so surgical intervention was employed . as with uncomplicated cholecystitis ,
laparoscopic techniques are favorable compared to open surgery and thus a laparoscopic cholecystectomy was undertaken in this case .
the gallstones removed during cholecystectomy were of orange - brown color consistent with cholesterol stones .
although fistula formation is now a rare complication of cholecystitis , it remains a possibility and should be considered in the differential diagnosis of any fistulous tract in the right abdominal wall .
we have demonstrated that previous percutaneous drainage of an acute gallbladder infection can promote the formation of such a fistula if the infection is not properly dealt with or re - occurs .
physicians should be prepared to recognize this complication in patients after drain removal and prior to definitive surgery .
 cases of cholecystocutaneous fistulas are now a rare occurrence as a result of rapid diagnosis and treatment . 
 we present a case of cholecystocutaneous fistula developing after the removal of a percutaneous drain for the treatment of acute cholecystitis . 
 re - occurring infection and presence of gallstones led to fistulization of the gallbladder fundus and the development of a tract along the path created by the drain . the patient presented with re - occurring right upper quadrant abdominal pain , purulent discharge from the fistulous opening and expulsion of multiple gallstones . 
 she underwent laparoscopic cholecystectomy and fistula excision . 
Introduction
Case Report
Discussion