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Small bowel obstruction and choledocholithiasis

Case contributed by Vikas Shah
Diagnosis certain


3 days of abdominal distension and vomiting. Previous surgery for rectal cancer.

Patient Data

Age: 65 years
Gender: Male

Acute high-grade small bowel obstruction with transition point involving mid small bowel in the pelvis with acute angulation and kinking, bubbly matter proximally indicating 'small bowel feces sign'. No perforation, no free fluid, no mesenteric congestion. Multiple high-density stones within common bile duct. No intrahepatic duct dilatation.

Large hiatus hernia. Left common iliac artery appears occluded. 

Gastrografin challenge


Gastrografin has passed through into the large bowel 4 hours after administration, indicating no ongoing small bowel obstruction - this is a "successful" or passed water-soluble contrast challenge.

MRCP confirms a number of stones within the gall bladder and common bile duct (at least 4 in the duct), with no intrahepatic duct dilatation. The small bowel obstruction is also seen to have resolved. Large hiatus hernia with nasogastric tube within stomach.

Case Discussion

On the CT, the small bowel feces sign is a helpful indicator of where to find the transition point, and the abrupt angulation and kinking of the small bowel, particularly given the history of prior abdominal surgery, indicates adhesions as the likely cause of the obstruction. Passage of Gastrografin into the large bowel at 4 hours indicates a successful water-soluble contrast challenge. The MRCP confirms the CT finding of cholelithiasis and choledocholithiasis, and also shows the nasogastric tube traversing the hiatus hernia with the tip in the infradiaphragmatic stomach.

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