Presentation
Progressively worsening epigastric abdominal pain associated with abdominal tenderness to palpation, nausea, and vomiting.
Patient Data
The gallbladder is enlarged. Within its lumen, there are multiple, large areas of hypoattenuation which likely represent gallstones. Within the most anterior gallstone, there is a small focus of hypoattenuation which may represent gas-fissuring.
Again seen is a large gallbladder with multiple large, hypoattenuating gallstones. There is a cholecystoduodenal fistula and an almost inseparable gallbladder and duodenum. There is pneumobilia in the left lobe of the liver and foci of air seen within the gallbladder.
The stomach is moderately dilated and predominantly fluid-filled.
Gallbladder/biliary tree:
Case Discussion
This is a case of Bouveret's syndrome (gastric outlet obstruction due to an impacted gallstone in either the pylorus or proximal duodenum), which is seen on both CT and MRI in this case.
Operative notes indicate that as an endoscope was advanced into the stomach, a large stone was seen within the lumen of the duodenal bulb. Given the size, it was not amendable to endoscopic retrieval. The case was converted to an open gastrotomy with extraction of three gallstones >5 cm each. The patient did well post-operatively. and was discharged 1 week after the surgery.
Co-author:
Christine Cooley, MD
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