Presentation
Vomiting. Admitted for follow-up.
Patient Data
Supine and cross-table AP films showed dilated small bowel loops in a stepladder configuration, measuring up to 5 cm in diameter and containing air-fluid levels. Small bowel loops are more dilated compared with radiographs from the previous day (not shown), which were suspicious for partial small bowel obstruction.
Intravenous contrast material not administered due to chronic renal failure.
Streak artifacts due to ECG leads.
Nasogastric tube in the stomach.
Right basal pulmonary consolidation with air bronchogram. Moderate right-sided pleural effusion.
Cholecystoduodenal fistula evident with an air-contrast material level in the gallbladder and pneumobilia in the left biliary tree and common bile duct.
Large duodenal diverticulum in segment 2 measuring 5.0 cm in diameter.
Dilated small bowel loops, up to 3.8 cm in diameter, containing multiple air-fluid levels. Large laminated noncalcified gallstone measuring 4.7 x 2.3 cm in the terminal ileum, with intraluminal contrast material around it and along the colon and rectum. The cecum is collapsed, with several small diverticula and a small intramural lipoma.
Two exophytic cystic lesions in the right kidney, the larger measuring 2.5 cm in diameter - most probably renal cysts.
The urinary bladder is catheterized and empty, with two diverticula in its anterior wall.
Numerous sigmoid diverticula.
Small left inguinal hernia containing fat.
Case Discussion
This case nicely demonstrates gallstone ileus with partial small bowel obstruction.
Incidentally, the patient had quite a few diverticula: duodenal, sigmoid, and urocystic.
An important lesson to be learned from this case is to remove all removable metal objects from the patient prior to scanning, lest they cause harsh artifacts.
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