Presentation
Nausea and vomiting with patient stating, "I am unable to keep food down."
Patient Data
There is pneumobilia and air within the gallbladder. The gallbladder is contracted and inflamed. The previously seen large gallbladder stone on prior CT (not shown) is no longer in the gallbladder and is likely in the inflamed duodenal bulb. The stomach is distended with fluid. The duodenum and small bowel distal to the bulb are decompressed. Findings likely represent new gallbladder fistula to the duodenal bulb, and a suspected large gallbladder stone has passed into the duodenal bulb causing gastric outlet obstruction.
Cardiomegaly, pulmonary vascular congestion, and small pleural effusions, likely representing congestive heart failure.
There is a 2.8 x 2.7 cm exophytic enhancing mass in the anterior mid right kidney. There is a non-obstructing calculus in the mid right kidney. There are several left renal cysts.
Myomatous uterus.
Chronic loculated collection in the lower anterior abdominal wall not clinically significant.
Degenerative spine changes.
Rigler's triad: air within the gallbladder (blue arrow), cholecystoenteric fistula (red arrow) with ectopic gallstone in proximal duodenum, and gastric distention (yellow arrow).
Interval placement of Gastrojejunostomy (G-J) tube with the balloon external to the gastric lumen and within the ventral abdominal subcutaneous tissues/musculature. There is new small to moderate amount of pneumoperitoneum secondary to gastric perforation from displaced G-J tube. The G-J tube tip is within the proximal jejunum.
Nasogastric tube is also present with tip in the body of the stomach. There is resolution/decompression of the gastric outlet obstruction.
There is a persistent cholecystoenteric fistula with the proximal duodenum and a small amount of air within the gallbladder. There is a rim calcified gallstone within the proximal duodenum, better visualized on this study compared to the original CT.
Remaining findings are unchanged.
Case Discussion
One year prior patient received a CT scan demonstrating a large calcified gallstone within the gallbladder (images not shown). One year later the CT scan showed pneumobilia, cholecystoenteric fistula, and gastric outlet obstruction secondary to ectopic gallstone in the proximal duodenum known as Bouveret’s syndrome. Bouveret’s syndrome has the same pathophysiology as gallstone ileus, but instead of the ectopic gallstone causing obstruction/ileus in the distal small bowel (most common terminal ileum) in a rarer event the stone is lodged in the proximal duodenum or gastric pylorus causing gastric outlet obstruction, as in this case. Findings of gallstone ileus or Bouveret’s syndrome may exhibit Rigler’s triad of pneumobilia, ectopic gallstone, and bowel obstruction, like in this case which showed all three findings.
A few weeks later another CT scan was performed because of displacement of the gastrojejunostomy tube which was associated with pneumoperitoneum. The ectopic gallstone within the duodenum was more conspicuous on the latest CT scan.
The ectopic gallstone was treated by endoscopic lithotripsy. Patient’s symptom improved and she was stable at discharge.