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WHO declared worldwide outbreak of COVID-19 a pandemic on 11 March 2020. Healthcare authorities have temporarily stopped all elective surgical and endoscopy procedures. Nevertheless, there is a subset of patients who require emergency treatment such as aerosol-generating procedures. Herein, we would like to discuss the management of a patient diagnosed with impending biliary sepsis during COVID-19 outbreak. The highlight of the discussion is mainly concerning the advantages of concurrent use of aerosol protective barrier in addition to personal protective equipment practice, necessary precautions to be taken during endoscopy retrograde cholangiopancreatography and handling of the patient preprocedure and postprocedure., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A biliary fistula which may occur spontaneously or after surgery, is an abnormal communication from the biliary system to an organ, cavity or free surface. Spontaneous biliary-enteric fistula is a rare complication of gallbladder pathology, with over 90% of them secondary to cholelithiasis. Approximately 6% are due to perforating peptic ulcers. Symptoms of biliary-enteric fistula varies widely and usually non-specific, mimicking any chronic biliary disease. Cholecystoduodenal fistula causing severe upper gastrointestinal (UGI) bleed is very rare. Bleeding cholecystoduodenal fistula commonly requires surgical resection of the fistula and repair of the duodenal perforation. We describe the case of a previously healthy older patient who initially presented with symptoms suggestive of UGI bleeding. Bleeding could not be controlled endoscopically. When a laparotomy was performed, a cholecystoduodenal fistula was discovered and bleeding was noted to originate from the superficial branch of cystic artery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)