Cholecystoenteric Fistula Masquerading as a Bleeding Subepithelial Mass

Area of Science:

• Gastroenterology
• Diagnostic Imaging
• Surgical Pathology

Background:

• Subepithelial duodenal masses can present with varied symptoms, necessitating advanced diagnostic techniques.
• Endoscopic ultrasound (EUS) is crucial for characterizing duodenal lesions and guiding further management.
• Rarely, gastrointestinal pathology can manifest as a mass-like lesion, complicating diagnosis.

Observation:

• An 82-year-old male presented with coffee-ground emesis, leading to the discovery of an ulcerated duodenal subepithelial mass.
• EUS revealed a 21-mm hypoechoic, ulcerated mass with a duct-like structure in the duodenal sweep.
• During EUS, the lesion's ulceration opened into a fistulous tract, draining bile and gallstones.

Findings:

• The duodenal lesion was identified as a cholecystoenteric fistula, a direct communication between the gallbladder and the duodenum.
• Abdominal imaging confirmed the fistula's connection to the gallbladder, which contained an air-fluid level.
• The fistula presented as a subepithelial duodenal mass, demonstrating a rare diagnostic mimicry.

Implications:

• This case underscores the importance of considering rare diagnoses, such as cholecystoenteric fistulas, in the differential diagnosis of duodenal masses.
• Accurate diagnosis through advanced imaging like EUS is critical for appropriate treatment and patient outcomes.
• Understanding such presentations can improve diagnostic accuracy and patient management strategies for complex gastrointestinal conditions.