72yrs old male was referred for hepatobiliary scintigraphy because of complaints of right upper quadrant abdominal pain, made worse by defecation. Dynamic 1 min/ frame images of the abdomen were acquired in anterior projection after intravenous administration of 6.7 mCi of Tc-99m labeled mebrofenin (Choletec).

The images show good uptake by the liver suggesting adequate hepatocellular function. Activity is seen entering the common bile duct and the gall bladder, excluding cystic duct obstruction/ acute cholecystitis. Towards the end of 1 hr of imaging, the gall bladder activity is seen to move in the pattern of transverse colon and abrupt cutoff is seen in the common bile duct, without any small bowel activity. These findings suggest cholecysto-colonic fistula and partial common bile duct obstruction.

Cholecysto-colonic fistula was confirmed on barium enema. Supporting findings seen on the CT scan included the presence of air in the gall bladder and loss of fat plane between the gall bladder and the hepatic flexure of colon. Sphinterotomy was done on the follow up ERCP and multiple large stones were removed from the CBD.

This case was compiled by Dr. David He, BCM