Sheu B S, Shin J S, Lin X Z, Lin C Y, Chen C Y, Chang T T, Chen C Y, Cheng P N
Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan, ROC.
Am J Gastroenterol. 1996 Jan;91(1):122-6.
Choledochoduodenal fistula (CDF) is occasionally found during endoscopic retrograde cholangiopancreatography (ERCP). Cholelithiasis is suspected to be the leading cause in some endemic areas. We focus on this cause of CDF to determine which clinical characteristics are relevant to formation of fistulas and to learn whether CDF of various types would imply different clinical significance.
In 1882 ERCP studies from 1988 to 1993, we found 27 CDF with cholelithiasis in 1066 patients. Their clinical backgrounds and ERCP findings were compared with those of 492 patients who had cholelithiasis but no CDF.
The prevalence of CDF was 2.53%. A longer past history of biliary stones, recurrent biliary tract infection (BTI), and the presence of common bile duct stones (CBS) were factors relevant to the formation of fistula. In the case of 24 distal fistulas, including seven of type I and 17 of type II, there was concurrent distal CBS. Three cardinal features of fistula of the distal type were: 1) the length of CDF was less than 1.5 cm, 2) its orifice was just around or on the papillary fold, and 3) all cases of distal type II had prominent pneumobilia, less jaundice, and larger CBS than type I. Aggressive endoscopic or surgical treatment of distal type CDF decreased the recurrence of BTI, as indicated by surveillance for 1 yr. Three fistulas of the proximal type were longer and drained into the duodenum far from the papilla. All of these cases deserved early surgical intervention.
CDF really serves as a chronic sequel of cholelithiasis. Different clinical features of CDF of various types help one to establish diagnosis and treatment. To avoid recurrence of BTI, aggressive therapy to correct CDF is mandatory.
内镜逆行胰胆管造影术（ERCP）偶尔会发现胆总管十二指肠瘘（CDF）。在一些流行地区，胆结石被怀疑是主要病因。我们聚焦于CDF的这一病因，以确定哪些临床特征与瘘管形成相关，并了解不同类型的CDF是否意味着不同的临床意义。
在1988年至1993年的1882例ERCP研究中，我们在1066例患者中发现27例合并胆结石的CDF。将他们的临床背景和ERCP检查结果与492例有胆结石但无CDF的患者进行比较。
CDF的患病率为2.53%。胆结石病史较长、反复胆道感染（BTI）以及胆总管结石（CBS）的存在是与瘘管形成相关的因素。在24例远端瘘中，包括7例I型和17例II型，同时存在远端CBS。远端型瘘的三个主要特征是：1）CDF长度小于1.5 cm，2）其开口恰好在乳头皱襞周围或之上，3）所有II型远端瘘的气肿性胆汁更明显、黄疸较轻且CBS比I型更大。对远端型CDF进行积极的内镜或手术治疗可降低BTI的复发率，1年的随访表明了这一点。3例近端型瘘较长，引流至距乳头较远的十二指肠。所有这些病例都应尽早进行手术干预。
CDF确实是胆结石的慢性后遗症。不同类型CDF的不同临床特征有助于诊断和治疗。为避免BTI复发，必须积极治疗以纠正CDF。
