Presentation
Vomiting, abdominal pain, unwell.
Patient Data
Slightly distended stomach.
Unremarkable bowel gas pattern.
Degenerative changes right hip.
Pneumobilia.
Gallbladder fistulated to duodenum.
Inflammatory stranding surrounding duodenum.
Distended stomach, duodenum and jejunum to the level of the proximal jejunum where there is an abrupt change in caliber.
Some foci of fat density at the transition point.
On the zoomed view, impression of an intraluminal mass effect with absence of valvulae conniventes markings immediately proximal to the transition point - appearances are of mechanical obstruction secondary to a radiolucent gallstone.
Normal enhancement of small bowel with no features of ischemia.
Other findings - Uncomplicated colonic diverticulosis. Bilateral renal cysts, scarring, cortical thinning and non-specific perinephric fluid.
Advanced degenerative changed right hip.
A gallstone the size of a hen’s egg was palpated in the jejunum and resected by enterolithotomy.
Case Discussion
The gallstone was resected and the patient made a full and prompt recovery.
The presence of pneumobilia and an cholecystoduodenal fistula raises the suspicion for an ectopic gallstone as a cause of small bowel obstruction.
This radiolucent gallstone is challenging to visualize, and the clues to its location are some fat density within and the mass effect it exerts on the bowel wall with non-visualization of the valvulae conniventes.
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