Surgical management of acute cholangitis associated with a spontaneous biliodigestive fistula after failed endoscopic treatment: a rare case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Choledochoduodenal fistula (CDF) is a rare but important cause of cholangitis, involving an abnormal connection between the common bile duct and the duodenum. It presents with variable clinical symptoms and can complicate management.

CASE PRESENTATION: We report a rare case of acute cholangitis in a 65-year-old patient with a spontaneous CDF. The patient presented with abdominal pain, febrile jaundice, and signs of cholangitis. Computed tomography (CT) imaging revealed aerobilia and hyperdense material in the common bile duct, suggestive of a CDF, which was confirmed by biliary magnetic resonance imaging (MRI). After a failed endoscopic drainage, the patient underwent a successful Roux-en-Y hepaticojejunostomy.

CLINICAL DISCUSSION: CDFs are most commonly caused by bile duct inflammation due to gallstones, though other etiologies include duodenal ulcers, pancreatic tumors, and adjacent organ inflammation. Imaging, especially CT and cholangio-MRI, is key to diagnosis. Management ranges from conservative therapy to surgical intervention, depending on the clinical context.

CONCLUSION: CDF should be considered in patients with cholangitis or pancreatitis with unexplained aerobilia. Diagnosis relies heavily on imaging, and treatment - though not standardized - may require surgical management when endoscopic methods fail.