Presentation
Several days of abdominal pain. Acute on chronic kidney injury. Bilateral ureteric stents. Check stent position.
Patient Data
A large calcified gallstone in the second part of the duodenum is causing proximal dilation of the duodenum and significant dilation of the stomach in keeping with gastric outlet obstruction. A smaller gallstone is more proximally located. There is pneumobilia with a cholecystoenteric fistula evident. The small bowel is collapsed distal to the obstruction.
Bilateral ureteric stents in situ in appropriate position extending from the right renal pelvis and left renal calyces to the bladder. There is moderate dilatation of the renal pelvis bilaterally. Thickening of the tissues of the right flank likely represents previous instrumentation in relation to the previous perirenal abscess. No recurrent abscess is identified. Indwelling catheter in situ.
There is a midline anterior abdominal wall hernia containing non-obstructed small bowel.
No enlarged intra-abdominal lymph nodes.
Patchy ground glass change in the left lung base, likely reflects infection. Grade 3 anterolithesis of L5 on S1.
Conclusion
Gastric outlet obstruction at level of the duodenum secondary to an ectopic gallstone from a cholecystoenteric fistula, in keeping with Bouveret syndrome.
Case Discussion
The patient proceeded to surgery for open duodenectomy:
- midline laparotomy
- large palpable gallstone in D2/3
- kocherization of duodenum limited by cholecystoduodenal fistula superiorly
- longitudinal duodenotomy over large gallstone on anterolateral aspect of D2/3
- gallstone delivered, smaller gallstone more proximal also removed.
- closed with omental patch
The patient recovered well, nil complications.