45 year old patient presents with acute cholecystitis. Blood investigation showed raised bilirubin. His pain resolved over the period but raised Bilirubin persisted. ERCP showed cholecystocholedochal fistula. What is the probable diagnosis
**Core Concept**
Cholecystocholedochal fistula is an abnormal communication between the gallbladder and the common bile duct, leading to a complex clinical presentation. This fistula can cause cholangitis, pancreatitis, and obstruction of bile flow, resulting in elevated bilirubin levels.
**Why the Correct Answer is Right**
The presence of a cholecystocholedochal fistula in this patient explains the elevated bilirubin levels, despite resolution of pain. This is because the fistula allows bile to flow from the common bile duct into the gallbladder, bypassing the normal bile ducts and causing obstruction in the biliary tree. This leads to a buildup of bilirubin in the blood, resulting in jaundice.
**Why Each Wrong Option is Incorrect**
* **Option A:** This option is not relevant to the clinical presentation of a cholecystocholedochal fistula. The patient's symptoms and lab results do not suggest a diagnosis of primary biliary cirrhosis.
* **Option B:** While a choledocholithiasis can cause elevated bilirubin levels, it does not explain the presence of a cholecystocholedochal fistula or the persistent elevation of bilirubin despite resolution of pain.
* **Option C:** A Mirizzi's syndrome is a condition where a gallstone becomes impacted in the cystic duct and causes obstruction of the common bile duct. However, this does not explain the presence of a cholecystocholedochal fistula.
**Clinical Pearl / High-Yield Fact**
A cholecystocholedochal fistula is a rare but serious complication of gallbladder disease, and its diagnosis requires a high index of suspicion in patients with persistent elevation of bilirubin levels despite resolution of pain.
**Correct Answer: C. Mirizzi's syndrome is not the correct diagnosis in this case. However, since the question is incomplete, I will provide a likely answer.**