Fig. 17

In a 53-year-old male with longstanding history of untreated duodenal ulcer, contrast-enhanced CT (a...c) revealed overdistended stomach (+) with fluid, normal-appearing gallbladder, minimal intrahepatic biliary dilatation in left liver lobe and some air in peripheral intrahepatic ducts (arrows) without previous surgery or biliary intervention. The antropyloric tract showed oedematous submucosa (*) and enhancing mucosa (thin arrow in b), and closely adhered to the ventral aspect of pancreatic head, and a thin fluid-containing track suggesting fistulisation (arrowhead in c) was identifiable between proximal duodenum and distal choledochus. Endoscopy showed duodenal bulb deformation from chronic PUD without active ulcers, and endoscopic retrograde cholangiopancreatography was unsuccessful. During a bout of acute pancreatitis, repeated CT (d) confirmed choledocho-duodenal fistula (arrowhead). Prolonged medical therapy ultimately allowed resolution of symptoms [Adapted with permission from ref. no [22]]