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An 84-year-old woman presented with acute worsening of diarrhoea for a few weeks, with a background of chronic diarrhoea over the past 12 months accompanied by weight loss. Computed tomography during this admission revealed air in the biliary tree and resolution of gallstones in keeping with a cholecystocolonic fistula. Owing to her comorbidities, surgical management was deemed not to be the best option. She was trialled on octreotide, a somatostatin analogue, which effectively resolved her symptoms. This case presents an effective and novel method of managing cholecystocolonic fistulas conservatively in a patient where medical therapy is the ceiling of care.

The ratio of the bilirubin concentration in abdominal drainage fluid to the serum bilirubin concentration (d-Bil/s-Bil) has been used as a predictor of biliary fistula (BF) formation after hepatobiliary surgery. The d-Bil/s-Bil ratio is highly influenced by the amount of drainage and is not always reliable, especially when the amount of drainage is large. In this study, the usefulness of the d-Bil/s-Bil ratio and total bilirubin amount in the drainage fluid (TBA) (bilirubin concentration in the drainage fluid x the amount of drainage) as predictors of severe BF (sBF) formation was evaluated retrospectively from the data of 306 patients who had undergone hepatobiliary surgery. Of the 306 patients, 201 patients were included in the training set and the remaining 105 in the validation set, to determine the best parameter to predict sBF formation after hepatobiliary surgery. Receiver-operating characteristic curve analysis revealed that the predictive power of TBA was superior to that of the d-Bil/s-Bil ratio throughout the postoperative period, and that the TBA on postoperative day (POD) 1 showed the highest discriminatory power in the training set (area under the curve, 0.789; cutoff value, 470 mg/day). The TBA on POD 1 also showed the highest predictive power for sBF formation in the validation set, with a sensitivity of 100%, specificity of 97.1%, and accuracy of 97.1%. In conclusion, TBA may be a more reliable predictor of sBF than the conventionally used d-Bil/s-Bil ratio. Early prediction of sBF may be useful for early removal of unnecessary prophylactic drainage tubes after hepatobiliary surgery.

Crohn's disease (CD) is characterized by transmural inflammation of the gastrointestinal tract, which predisposes to the formation of fistula. Duodenal involvement occurs in less than 5% of cases and often leads to clinically relevant strictures. However, fistula formation in the duodenum is exceptional. Herein, we report an unusual case of duodenobiliary fistula due to CD occurring in a 65-year-old patient who was successfully treated by anti-tumor necrosis factor (TNF) agents. This case report highlights the efficacy of anti-TNF alpha agents in the treatment of a bilioenteric fistula because it increases the probability of clinical remission and mucosal healing and therefore reduces the need for surgical treatment which may be associated morbidity., (Copyright © 2016 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.)

The authors have investigated whether cyclosporine decreases the serum concentration of mycophenolic acid, the active principle of the immunosuppressant mycophenolate mofetil, and increases that of the inactive metabolite 7-O-mycophenolic acid glucuronide by reducing their enterohepatic recirculation. Rats were treated daily with methylcellulose (1.66 mL/kg PO) plus 0.9% NaCl (6 mL/kg IP), mycophenolate mofetil (20 mg/kg PO) plus 0.9% NaCl (6 mL/kg IP), methylcellulose (1.66 mL/kg PO) plus cyclosporine (5 mg/kg IP), and mycophenolate mofetil (20 mg/kg PO) plus cyclosporine (5 mg/kg IP). After 14 days a bile fistula was installed to measure the biliary excretion of the immunosuppressants and their metabolites. After 90 minutes blood was taken to determine their concentrations in blood or serum by HPLC. Cyclosporine significantly decreased the serum concentration of mycophenolic acid by 39% and increased, not significantly, that of 7-O-mycophenolic acid glucuronide by 53%. The biliary excretion of 7-O-mycophenolic acid glucuronide was significantly reduced by cyclosporine by 57%, whereas that of mycophenolic acid was not affected. Mycophenolate mofetil did not show a significant effect on either the blood concentration or the biliary excretion of cyclosporine and its metabolites AM1, AM9, AM1c, and AM4N. Cyclosporine significantly decreased the serum concentration of active mycophenolate acid and increased, not significantly, the serum concentration of inactive 7-O-mycophenolic acid glucuronide, presumably by reducing the biliary excretion of this inactive metabolite.

Background: Biliary leakage is a problematic complication of hepatobiliary surgery. A novel alternative method is described that can obviate the need for reoperation for refractory biliary fistula., Methods: Nine patients with large biliary leaks unresponsive to endoscopic drainage underwent N-butyl-2-cyanoacrylate glue occlusion at ERCP., Results: In 7 patients, occlusion was successful with prompt control of the fistula in a single session, averting reoperation. In 1 patient there was a partial response and in another the treatment was unsuccessful. No procedure-related complication occurred over a median follow-up of 35 months (range: 1.6-160 months)., Conclusion: N-butyl-2-cyanoacrylate glue occlusion is a safe and effective endoscopic method for control of refractory bile leaks that eliminates the need for surgical reintervention.

Background: Current management of biliary fistulae includes percutaneous drainage and transpapillary endoscopic biliary stent placement. This study compared time to bile leak resolution for endoscopic stent insertion versus injection of botulinum toxin into the sphincter of Oddi., Methods: Thirty dogs underwent laparotomy and cholecystectomy without cystic duct closure. After a duodenotomy, dogs were randomized to the control group (Group 1) or one of two treatment groups. Treated dogs either underwent transpapillary stent placement (Group 2) or botulinum toxin injection into the sphincter of Oddi (Group 3). Drains were placed adjacent to the cystic duct stump and output was recorded daily. Resolution of bile leaks was defined as an output of less than 10 mL/day. Necropsy was performed to identify undrained intraperitoneal bile., Results: Data from 28 dogs were available for analysis. The numbers of days for resolution of bile leaks in Groups 1, 2, and 3 were, respectively, 9.3 (2.1) days, 2.3 (1.1) days, and 2.6 (1.1) days. There were significant differences in time to resolution of bile leak between Group 1 and both Groups 2 (p < 0.001) and 3 (p < 0.001). There was no significant difference between Groups 2 and 3 (p > 0.25)., Conclusion: Sphincter of Oddi injection with botulinum toxin is as effective as endobiliary stent placement in resolving cystic duct leaks in this canine model.

Bile leakage after hepatic resection often results in the formation of a biliary-cutaneous fistula. Such a fistula, when caused by an isolated bile duct in the remnant liver, can be intractable. We report a successful case of ethanol injection therapy of an isolated bile duct. A 73-year-old man underwent right hepatic resection for hepatocellular carcinoma. Bile leakage occurred after surgery, and the patient developed a biliary-cutaneous fistula. Fistulography revealed an isolated bile duct in the remnant portion of the caudate lobe without communication to the main biliary system. As conservative management with simple drainage was ineffective, injection therapy with ethanol was performed with a balloon occlusion catheter. After 11 therapy sessions, the bile duct was eradicated, and the biliary- cutaneous fistula was completely healed. The post-treatment course was uneventful. Ethanol injection therapy can be a choice for management of patients with a biliary fistula caused by an isolated bile duct., (Copyright 2002 Blackwell Publishing Asia Pty Ltd)

Bronchobiliary fistula is defined as the passage of bile in the bronchi and in the sputum (bilioptysis). This rare disorder is associated with significant morbidity. Authors review the anaesthetic management of bronchobiliary fistula and recommend the use of double lumen endotracheal tube even in cases with a closed/sealed bronchobiliary fistula.

A patient with post-laparoscopic cholecystectomy cystic duct leak successfully treated with conservative treatment is presented. The cystic duct leak was diagnosed through a CPRE where a Oddy sphyncter spasm was noted. The use of a topic Nytroglicerine resulted in a sphincter release and resolution of the fistula. A literature review of the importance of CPRE in the diagnosis and treatment of biliary injuries was carried out. In patients with nondilated bile ducts where the sphincterotomy or endoprothesis undergo with high morbidity, the use of topic nitroglycerine could be an effective alternative procedure.

Somatostatin is a potent inhibitory hormone, it's synthetic analogue is more potent and has a prolonged action. It has a wide range of actions in the gastrointestinal system; among which is an anticholeritic action on bile secretion. The use of Sandostatin in the management of a case of complicated biliary fistula is reported; it controlled the fistula reducing its daily output from 200 ml to less than 5 ml per day.

Experience in the treatment of 43 patients with pyobiliary fistulas which formed after abscessotomy in amebic abscess of the liver is generalized. The fistulas occurred after open drainage in 29 patients, spontaneous opening of the abscess on the external surface of the body in 8, and after operation for transdiaphragmatic opening of a hepatic abscess in 6 patients. Two groups of patients were distinguished according to the method of completion of the operation. Among the 24 patients of the first clinical group 9 were subjected to drainage of the residual cavity with excision of the fistula, biliary fistulas opening into the cavity were closed in 5 patients, and routine drainage of the cavity was performed in other 5 patients. In 5 cases the operation was completed by plastics of the residual cavity with a pedicle diaphragmatic flap. In the second clinical group, filling of the cavity with the omentum was carried out in 13 patients and a variant of operation suggested by the author was used in 6 patients. The organism's immune reactivity was found to be reduced in prolonged existence of the fistula. The author recommends immunostimulants to be included in the therapeutic complex.

Somatostatin and its long-acting analog octreotide (SMS 201-995) inhibit several gastrointestinal functions. Their effects have been studied in the treatment of small numbers of external pancreatic, intestinal and biliary fistulas. We treated 8 biliary, 4 pancreatic and 5 intestinal cutaneous fistulas with octreotide. Mean decreases in fistula output before octreotide treatment were not significant (p > 0.01 for each group). On the 1st day of octreotide treatment, mean fistula output decreased from 412 +/- 60.4 to 234 +/- 57.7 ml in the biliary, from 457.5 +/- 57.5 to 217.5 +/- 11.8 ml in the pancreatic and from 564 +/- 49.2 to 217.5 +/- 11.8 ml in the enterocutaneous fistula groups (p < 0.01 for each). No serious side effects were recorded. We conclude that octreotide is an important adjunct in the conservative treatment of external biliary, pancreatic and intestinal fistulas, by decreasing their output.

The regulatory and secretory properties of cholylsarcosine (C-sar), a synthetic conjugated bile acid analogue that resists deconjugation and dehydroxylation, were compared with those of the natural conjugates of cholic acid. After continuous intraduodenal infusion of cholylsarcosine (C-sar), cholyltaurine (C-tau), or cholylglycine (C-gly) at 36 mumol/100 g.h, the infused bile acid in each case became the predominant biliary bile acid. After 48 hours, infusion of C-sar, C-tau, and C-gly suppressed the activity of cholesterol 7 alpha-hydroxylase (C7 alpha H; rate-limiting for bile acid synthesis) by 65%, 78%, and 92%, respectively, compared with biliary fistula controls. After C-sar infusion, levels of C7 alpha H protein, messenger RNA, and transcriptional activity were depressed to the same extent as specific activity, indicating that C-sar, like C-tau, down-regulates C7 alpha H principally at the level of gene transcription. All three bile acids also suppressed activity of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (rate-limiting for cholesterol synthesis). Both short- and long-term, the three cholyl conjugates caused similar increases in bile flow and in biliary secretion of cholesterol and phospholipid. It is concluded that in the rat, cholyl conjugates per se can suppress cholesterol and bile acid biosynthesis without prior conversion to deoxycholate. The effects of C-sar on hepatic cholesterol and bile acid synthesis as well as on induced bile flow and biliary lipid secretion are essentially identical to those of the naturally occurring cholyl conjugates.

Six patients with gastrointestinal fistulae treated with a potent inhibitor of gastrointestinal hormones, the somatostatin analogue SMS 201-995 are reported. All patients had severe intraabdominal diseases and underwent a mean of 3.5 surgery procedures during their hospital stay. When the patients were analyzed individually a mean reduction of 42.5% (P < 0.050 of basal fistulae output was observed after treatment. In three patients the fistulae closed after seven and ten days of treatment with the analogue; the other three patients died after a protracted hospital stay which included multiple admissions to the Intensive Care Unit. When the output of all fistulae treated where analyzed together it showed a tendency to decrease, but it didn't reach statistical significance.

The experience with antibacterial therapy in 120 patients with choledocholithiasis and cicatricial stricture of the bile ducts complicated by the development of an external biliary fistula is summarized. It was established that intravenous administration of antibiotics at the maximum dosages with purposeful sanation of the bile ducts via the external biliary fistula at the preoperative period improved the immediate and long-term results of treatment of the patients. Only in full-value, adequate correction of disorders in the major bile outflow, the reliable elimination of the external biliary fistula is possible.

The effect of treatment with a long acting analogue of somatostatin (SMS 201-995) administered by subcutaneous route 165 micrograms every eight hours in a patient with a external biliary fistula is reported. There was a significant reduction of the daily fistula output during treatment when compared with the basal periods (p = 0.04), with an average decrease of 270 ml/day during the first period of treatment and 357 ml/day when the drug was administered the second time (p = 0.04). There where not changes in the chemical composition of the bile neither adverse side effects were observed during treatment. These results suggest that SMS 201-995 might be useful in the treatment of external biliary fistulas.