Gastric volvulus associated with bronchobiliary fistula

A 67-year-old woman presented to hepatobiliary surgery department with a 3-month history of epigastric pain and loss of appetite, accompanied by paroxysmal cough and coughing up bile-like substance in the past week. She had a history of multiple operations for cholelithiasis. Laboratory evaluation revealed the following: white blood cell count, 10.4 × 10⁹/L (reference range, 3.5-9.5 × 10⁹/L); C-reactive protein, 65.28 mg/L (reference range, 0.0-8.0 mg/L); total bilirubin, 35.6 μmol/L (reference range, 1.71-21 μmol/L); direct bilirubin, 13.6 μmol/L (reference range, 0-7.32 μmol/L); indirect bilirubin, 22.0 μmol/L (reference range, 0-13.68 μmol/L); alkaline phosphatase, 334.7 U/L (reference range, 45-135 U/L). Upper gastrointestinal radiography (Figure 1A) showed rotation of the stomach along its long axis with reversal of the greater and lesser curvatures (red arrow), and right subphrenic nodular calcification (yellow arrow). Abdominal MR (Figure 1B and C) revealed gastric volvulus (red arrow), bile duct stone (yellow arrow), cholangiectasis with a fistulous towards thoracic cavity (green arrow). A laparoscopic approach revealed adhesion of the greater curvature to right upper abdomen, and the presence of a fistulous between bile duct and thoracic cavity after lithotomy. The fistula was sutured and the diaphragmatic defect was repaired. However, severe septic shock occured after operation and she was discharged 20 days after anti-infectious therapy. The patient was feeling well at 1 month of follow-up.