Cholangitis, Choledocholithiasis and a Cholecystocolonic Fistula: A Case Report on a Rare Triple Surgical Challenge.

Cholecystocolonic fistula (CCF) is an uncommon complication of gallstone disease and is usually diagnosed intraoperatively. Concomitant choledocholithiasis and acute cholangitis create competing priorities: urgent biliary drainage and definitive treatment of the fistula. A 78-year-old woman presented with 3 days of upper abdominal pain, fever, vomiting and jaundice. She was febrile and hypotensive but stabilised after intravenous fluid resuscitation without vasopressors. Laboratory and imaging findings met Tokyo Guidelines 2018 criteria for severe acute cholangitis. Computed tomography demonstrated an 11 mm impacted distal common bile duct (CBD) stone, severe biliary dilatation, pneumobilia and a large calcified gallstone in the hepatic flexure, consistent with CCF and gallstone migration. After resuscitation and correction of coagulopathy, she underwent surgery within 24 h. Laparoscopy confirmed the fistula, and intraoperative cholangiography showed multiple obstructing ductal stones. Several stones were removed transcystically; however, an impacted distal stone required conversion to open choledochotomy. Cholecystectomy, right hemicolectomy with ileocolic anastomosis, and primary CBD closure were completed during the same operation. Postoperative bilious drainage prompted further imaging and endoscopic retrograde cholangiopancreatography (ERCP). Imaging demonstrated a cystic duct stump leak, while ERCP confirmed retained choledocholithiasis. Sphincterotomy and balloon extraction achieved ductal clearance, and a plastic CBD stent was inserted. The leak subsequently resolved, and the stent was removed approximately 4 months later, with no residual choledocholithiasis identified. Histopathology excluded malignancy. This case illustrates that single-stage biliary and colonic surgery may be feasible in a resuscitated, haemodynamically stable patient with severe cholangitis when appropriate expertise is available. It also supports a low threshold for postoperative ERCP when ductal clearance remains uncertain.