Ectopic Gallstone Research Articles

Early onset Bouveret syndrome: a unique case in a young patient

BackgroundBouveret syndrome is a rare etiology of gastric outlet obstruction, presenting with clinical manifestations that resemble those of several gastric pathologies. Timely diagnosis is imperative to mitigate potentially fatal consequences associated with this condition.Case presentationThis case report involves a male patient, aged 35, who exhibited symptoms of intense abdominal discomfort, nausea, and vomiting over a 24-h period. The individual experienced identical symptoms of lesser intensity on three separate occasions throughout the preceding 4-month period, during which they resorted to analgesic medication for temporary relief. A contrast-enhanced computed tomography (CT) scan of the abdomen was performed, which identified the presence of the Rigler triad, characterized by pneumobilia, a cholecysto-antral fistula, and an ectopic gallstone lodged in the gastric antrum resulting in an obstruction. The patient’s diagnosis of Bouveret syndrome was determined based on the imaging findings. A surgical procedure known as cholecystectomy was conducted, which confirmed the existence of the sizable cholecystoduodenal fistula that was previously detected in the computed tomography (CT) scan. The surgical procedures that were conducted included a partial duodenectomy, a gastrojejunostomy, a cholecystectomy, and a common bile duct exploration with the removal of common bile duct stones. After examining the bile duct, a t-tube was inserted into the bile duct.ConclusionThis case demonstrates a distinctive occurrence of a condition in a young man, typically observed in elderly females. There is a lack of established treatment guidelines for this particular entity. The appropriate course of action depends on various factors, including the patient’s condition, CT scan results, medical history, presence of co-existing illnesses, and intraoperative circumstances. These considerations are taken into account when determining whether a single-step surgical strategy or a multi-step approach should be pursued in order to minimize complications in patients. In this case, due to favorable conditions, a single-step approach was taken that yielded promising results.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

TH7.6 Recurrent Gallstone Ileus: A Case Report

Abstract Introduction Gallstone Ileus (GSI) is a rare cause of mechanical bowel obstruction secondary to impaction of an ectopic gallstone within the bowel lumen. Recurrent GSI is rare, accounting for less than 3% of SBO. The main risk factors for recurrence include a large choleduodenal fistula, an active fistula or faceted gallstones. There is currently no mainstay approach to managing GSI, with “single-stage” and “two-stage” options advocated. Case A 73-year-old lady presented with epigastric pain and vomiting, and was shown to have an obstructing gallstone in the distal ileum. She underwent a laparotomy and enterolithotomy and initially made a good recovery. However, she represented three months later with similar symptoms and was found to have a jejunal gallstone causing proximal small bowel obstruction. She underwent a second enterolithotomy, and is planned for an interval cholecystectomy. Discussion The management of recurrent GSI include one of three options: enterolithotomy alone, “single-stage” (enterolithotomy, cholecystectomy and fistula repair) or “two-stage” approach (enterolithotomy and interval cholecystectomy). The optimal approach in management is still debated. The traditionally taught two-stage approach demonstrates a lower mortality and recurrence rate and shorter index procedure in the unstable patient, requiring a skillset common to most general surgeons. However, with increasing reports of recurrent GSI, a single-stage approach during the index procedure has been advocated, citing decreased risk of cholecystitis, cholangitis and repeat laparotomy in the event of recurrence. Our patient underwent emergency enterolithotomy on both presentations, however there may support for a “single-step” approach in certain patient cohorts.

Beyond acute cholecystitis—gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

S1560 Bouveret’s Syndrome; A Rare Cause of Gastric Outlet Obstruction

INTRODUCTION: Bouveret’s syndrome is an extremely rare cause of gastric outlet obstruction secondary to gallstone impaction in the duodenum or stomach via bilioenteric fistula. This syndrome is most commonly seen in elderly woman with multiple comorbidities and has been associated with mortality rates between 12-30%. CASE DESCRIPTION/METHODS: An 80-year-old female with a past medical history significant for diabetes, hypertension, and hyperlipidemia presented with two days of postprandial nausea and vomiting. Patient had no complaint of recent abdominal pain. CT of the abdomen and pelvis with oral contrast demonstrated a 2.2 cm mass with rim calcification considered to be the cause of gastric outlet obstruction (pneumobilia was not reported but present) [Image 1]. An EGD was performed and the endoscope was advanced through a widely patent pylorus. A 4 cm gallstone was noted just proximal to the duodenal sweep [Image 2]. A Roth net was able to partially grasp the gallstone but was unable to remove it through the pylorus [Image 3]. A lithotripsy biliary basket was not able to retrieve the stone across of the pylorus due to stone size, and mechanical lithotripsy was unsuccessful. An electrohydraulic lithotripsy probe was used for lithotripsy but was ineffective at completely removing the stone. The patient was then referred to surgery, and on the following day she underwent laparoscopic gastrotomy but the gallstone could not be located. An exploratory laparotomy was performed and the gallstone was discovered in the distal ileum, requiring an enterotomy for removal. There were no complications post-operatively and the patient recovered. DISCUSSION: Bouveret’s syndrome is the rarest form of gallstone ileus occurring in only 1-3% of cases. Often patients present with vague abdominal symptoms which can delay diagnosis and appropriate treatment. Although present on 73% of CT images, Rigler’s triad (small bowel obstruction, pneumobilia, and ectopic gallstone), which is specific to Bouveret’s syndrome, is only recognized preoperatively in 60% of cases. Endoscopic management should be considered as the first line management option, due to the minimally invasive approach. Unfortunately, as demonstrated in this case, endoscopic management is not successful in 30-40% of cases, and surgery is necessary. Our case also demonstrates the risk of endoscopic intervention as the stone was found lodged at the ileocecal valve likely precipitated by stone manipulation emphasizing need for coordination with surgery.Figure 1.: Image 1 – CT of the abdomen and pelvis demonstrating Rigler’s triad: 2.2 cm in size rim calcified mass (blue arrow), gastric distention consistent with obstruction (orange arrow), and an abnormally thickened gallbladder (yellow arrow) with pneumobilia (green arrow).Figure 2.: Image 2 – Endoscopic view of gallstone obstructing duodenum just proximal to the duodenal sweep.Figure 3.: Image 3 – Endoscopic view of the gallstone as an attempt is made to pull gallstone through pylorus via Roth net.

Rigler’s triad in a case of gallstone ileus

Background: gallstone ileus is a rare complication of cholelithiasis. It is defined as a mechanical obstruction of the small bowel due to impaction of large gallstones into the gastrointestinal tract, generally though a cholecystoduodenal fistula. Rigler’s triad (pneumobilia, ectopic gallstone and mechanical obstruction) occurs in 30% of the patients. Surgery is indicated and includes enterotomy with gallstone extraction. Objective: we report a case of gallstone ileus with radiographic evidence of Rigler’s triad

Evaluation and diagnosis of gallstone ileus using point of care ultrasound in the Emergency Department

A 75-year-old female presented to the Emergency Department (ED) with nausea, feculent emesis and abdominal distension. On previous visit the patient was diagnosed with a 2.2x1.9x1.1 cm ectopic gallstone in the mid small bowel without evidence of ileus or bowel obstruction and was subsequently discharged home. She returned 2 days later, abdominal plain radiographs revealed mildly dilated small bowel with air-fluid levels and a calcified mass in the right hemipelvis. Bedside ultrasound was performed and an air filled gallbladder with a fistulous tract was visualized. Dilated loops of bowel were visualized with an abnormal back and forth movement of intestinal contents, consistent with a small bowel obstruction. Patient went on to have an uncomplicated surgical extraction of the gallstone with resolution of her ileus. We would propose using point-of-care ultrasonography with abdominal plain films as an adjunct for evaluation and diagnosis of gallstone ileus in elderly patients.

Bouveret’s syndrome and cholecystogastric fistula: a case-report and review of the literature

An exceptionally rare cause of gastric outlet obstruction, Bouveret's syndrome results from proximal impaction of an ectopic gallstone, enabled by fistulization that aberrantly connects the biliary and luminal gastrointestinal tract, typically a cholecystoduodenal fistula. It occurs with a 2:1 female predominance, most often in the eighth decade of life. Endoscopic treatment is the preferred first-line strategy in management, followed by surgical intervention if unsuccessful. Endoscopy failed to retrieve the stone due to its size, despite attempted lithotripsy, which prompted laparoscopic retrieval. Bouveret's syndrome compels a high index of suspicion in proximal gastrointestinal obstruction even when presenting in a male a decade younger than the median age of diagnosis (74years), with no preceding biliary symptoms particularly as early intervention can considerably reduce morbidity and mortality.

Gastric Outlet Obstruction Due to Cholecysto-Gastric Fistula: Bouveret’s Syndrome

Bouveret’s syndrome is defined as gastrointestinal obstruction due to an impacted gallstone secondary to biliary-enteric fistula. This is often observed with nonspecific symptoms such as epigastric pain, nausea, and vomiting. The diagnosis is made by visualization of pneumobilia, gastric outlet obstruction and ectopic gallstone. In this report, we discussed an elderly patient who was admitted to the emergency department with abdominal pain and vomiting without any signs of bowel obstruction in plain x-ray and ultrasound imaging. We aimed to remind the importance of clinical suspicion and the diagnostic value of computed abdominal tomography for emergency physicians.

2584 Running Into a Stone Wall: A Rare Case of Gastric Outlet Obstruction

INTRODUCTION: Bouveret syndrome is an extremely rare and serious form of gallstone ileus with an incidence of 1-3% and a surgical mortality rate approaching 15-33 percent. Treatment often involves a combination of endoscopic and surgical interventions. We present a case of gastric outlet obstruction and duodenal ulceration caused by 3 impacted gallstones, treated ultimately with surgery. CASE DESCRIPTION/METHODS: A 57-year-old male with no known medical conditions was admitted to the intensive care unit with a one-week history of epigastric pain, nausea, and dark emesis. He was tachycardic and hypotensive on arrival. On exam, the patient was diaphoretic with dark-bloody return from the nasogastric tube. Hemoglobin was 5.6 g/dL (ref: 14.0-16.8 g/dL) with a leukocytosis of 17.69 K/uL (ref: 4.0-10.8 K/uL). Liver enzymes were unremarkable. Given concerns for an upper gastrointestinal bleed, patient underwent an esophagogastroduodenoscopy showing a 3-cm non-bleeding ulcer in the duodenal bulb, a cholecystoduodenal fistula, and a large impacted gallstone in the first portion of the duodenum distal to the fistula (Figure 1). Subsequent contrast-enhanced computed tomography demonstrated significant pneumobilia and a perforated duodenal ulcer (Figure 2). Removal of the obstructing gallstone was unsuccessful despite using a Raptor grasping device, Roth net retriever, and snare. Patient subsequently underwent exploratory laparotomy with cholecystectomy, pyloric exclusion, Roux-en-Y gastrojejunostomy, and duodenal enterorrhaphy with Graham patch (Figure 3). He tolerated the procedure well and was discharged to a rehabilitation facility. DISCUSSION: Bouveret Syndrome is a rare form of gallstone ileus characterized by gastric outlet obstruction secondary to gallstone impaction within the duodenum or pylorus through a cholecystoduodenal or choledochoduodenal fistula. Prompt imaging is warranted and in patients with gallstone ileus, may reveal pneumobilia, bowel obstruction, and ectopic gallstone, also known as Rigler's triad. Enterolithotomy, gastrostomy with cholecystectomy, and fistula repair are considered the mainstay of management, but prompt gastroenterological evaluation is warranted to evaluate the possibility of mechanical extraction or stone fragmentation.

Spontaneous cholecystoduodenal fistula - spectrum of complications

Introduction. Spontaneous cholecystoduodenal fistula is a rare complication of the gallbladder calculosis. Bowel obstruction is the complication in less than 1% of these patients. The pathognomonic triad (Rigler triad) of pneumobilia, small-bowel distention, and ectopic gallstones is typical for gallstone ileus. In only 1?3% of the patients with bowel obstruction by ectopic gallstone the localization of obstruction is in the duodenum, and it is called Bouveret syndrome. The rarest complication is a floating non-obstructing gallstone trapped in the stomach. Outline of cases. We present three elderly female patients with persistent abdominal pain and known gallbladder calculosis in the patients? histories. Plain radiography of the thorax and abdomen and ultrasound were performed as the first choice and contrast-enhanced computer tomography (CT) was done subsequently. In the first patient, CT and magnetic resonance imaging (MRI) showed signs of pneumobilia, cholecystoduodenal fistula, and the presence of the gallstone in the stomach. The iodine contrast X-ray swallow test revealed a cholecysto-duodenal bulb fistula and floating calculus in the stomach, confirmed by endoscopy. In the second patient with persistent abdominal pain, CT and barium swallow test showed signs of pneumobilia, cholecystoduodenal fistula, and two ectopic gallstones obstructing duodenum ? Bouveret syndrome. The third case showed signs of the Rigler triad ? typical signs of gallstone ileus. Conclusion. Spontaneous cholecystoduodenal fistula is a rare condition with possible complications such as Bouveret syndrome, gallstone ileus and floating, non-obstructive gallstones in the stomach, as the rarest possible complication. CT, MRI with magnetic resonance cholangiopancreatography, as well as the contrast X-ray swallow test can be very helpful in the detection of the bilio-enteric fistula and ectopic gallstones.

Small Bowel Obstruction From Ventral Hernia Mesh Eroding into the Bowel and Turning into a Bezoar

Intro: As hernia operations become more common, so do their complications which include infection, chronic pain, fistula formation, and adhesion formation to bowels. Ventral hernia repair can be performed using pre-peritoneal or intra-peritoneal methods. A disadvantage of the intra-peritoneal method is adhesions and irritations from the contact of the mesh with the bowel leading to higher incidence of visceral and vascular injuries. Most cases of erosion are reported in the literature to involve the urinary bladder and the vaginal cavity. Mesh migration is an infrequent occurrence. There are reports of mesh migrating into viscous organs causing a variety of symptoms including a recurrent hernia, infection, and obstruction. Case Presentation: A 65-year-old man with the history of ventral hernia repair using polypropylene mesh in the past, and no other medical history presented to the hospital with nausea, vomiting, and abdominal pain. He had not passed flatus or had a bowel movement in 3 days and had experienced abdominal distension. Prior to this presentation, the patient had intermittent chronic abdominal pain, with nausea and vomiting for many years following his operation. In the exam, the patient was with a distended abdomen. His CT Abdomen /pelvis showed small bowel obstruction from what was initially thought to be ectopic gallstone. However, the patient had a gallbladder of 3mm on CT and no Air in the biliary tree. General surgery was consulted and patient was taken to the operating room where intraluminal mass obstructing the distal ileum was extracted. Intraoperatively small bowel was adhered to the site of the previous hernia operation. After extensive washout of the bezoar, a polypropylene mesh was extracted from the Bezoar.Discussion: Mesh erosion and migration into the intestine, although very rare, is a possible late complication of intraperitoneal hernia repair. At first glance this presentation may appear similar to gallstone ileus with the diagnostic criteria of SBO, ectopic gallstone of either rim-calcified or total-calcified, and abnormal gallbladder, however in this patient lack of air in biliary tree hints at lack of Cholecystduodenal fistula or cholecystcolonic fistula in this patient and we must look for other causes of SBO.2553_A Figure 1. Bezour found in CT imaging at transition point of SBO2553_B Figure 2. Polypropelene Mesh Extracted from The Bezoar

Pseudo-Riglerʼs Sign With Intrabiliary Reflux of Gastrografin Due to Severe Constipation

Introduction: Rigler's triad, a manifestation of gallstone ileus, is constituted by the radiographic finings of ectopic gallstone, pneumobilia and small bowel obstruction. We report this very rare case of pneumobilia and reflux of oral Computerized Tomography (CT) contrast-Gastrografin into the biliary tree, in a patient with bowel obstruction/severe ileus due to constipation without an ectopic gallstone (pseudo-Rigler's sign). Patient was treated with colonic enemas, polyethylene glycol, and nasogastric tube decompression with resolution of these radiological findings. Case report: Here in, we present a case of a 58-year-old man with medical history of systolic congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, peripheral vascular disease who presented with hypoxic respiratory failure due to pneumonia. Patient was intubated and put on mechanical ventilation. Patient was found to have worsening abdominal distension. Physical examination revealed diminished bowel sounds. CT scan of abdomen and pelvis showed diffuse dilation of large and small bowel with abundant stool in the sigmoid colon and rectum, Gastrografin contrast in dilated intrahepatic bile ducts and pneumobilia (Figure 1). The patient was managed with high colonic enemas, polyethylene glycol and nasogastric tube decompression. Electrolytes and renal function were monitored and corrected accordingly. The patient subsequently had bowel movements with resolution of ileus and pneumobilia with contrast drainage from bile ducts.Figure: Intrahepatic ducts with gastrografin.Discussion: Constipation commonly occurs in the elderly population. Severe or chronic constipation can very rarely lead to fecal impaction, intestinal obstruction and pneumobilia. Our patient presented with atypical signs of Rigler's triad (barring the ectopic gallstone) in the setting of chronic constipation. Patient was also found to have reflux of oral contrast material from the duodenum via the ampulla into the common bile duct and dilated intrahepatic biliary tree- which is an extremely rare radiological finding. To our knowledge this is the first reported case of biliary reflux of oral in the setting of chronic constipation.

Rare Cause of Gastric Outlet Obstruction

Case Report: Patient is a 75-year-old female who presented with 3-week history of nausea, vomiting and diffuse abdominal pain. On physical exam, her abdomen was distended and tender in the RUQ. CT scan of the abdomen and pelvis revealed marked dilation of the stomach with fluid, pneumobilia, and poor gallbladder visualization. The patient had no history of an abdominal surgery or ERCP. EGD showed Grade D esophagitis, excessive fluid in stomach and a large ulcerated area in second part of duodenum. Biopsies were negative for malignancy. A PET scan was suggestive of acute cholecystitis versus a cholocystoenteric fistula or malignancy. Repeat EGD a week later showed total resolution of the ulcerated area in the duodenum. EUS revealed peri-pancreatic inflammation and poor visualization of the gallbladder. Repeat CT scan revealed dilated proximal jejunal small bowel loops with transition zone and a 1.5 cm rounded structure in the jejunum. Patient was thought to have chronic cholecystitis causing perforation of the gallbladder with formation of a cholecystoenteric fistula resulting in gallstone impaction and small bowel obstruction. She underwent laparoscopic small bowel enterotomy with removal of gallstones from distal jejunum and proximal ileum. Patient slowly began eating and was discharged with uneventful post-operative course.Figure 1Figure 2Discussion: Bouveret syndrome is a rare cause of gastric outlet obstruction. It is a variant of gallstone ileus resulting in gastroduodenal obstruction. The stones enter the small bowel via cholecysto-enteric fistula. The average size is 4.6 cm compared to 2.5 cm for gallstone ileus. The most common presenting symptoms are abdominal pain, nausea and vomiting. The gold standard diagnostic test is EGD although CT scan, abdominal ultrasound and plain X-ray can be very helpful. Rigler's triad of pneumobilia, an ectopic gallstone, and dilated small bowel on abdominal x-ray is classic but is only seen in 30-35 % of cases. Classic CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum. Although the gastric outlet obstruction is almost always seen on EGD, the obstructing gallstone is seen only in 69 % of cases. Our patient, initially, presented with Bouveret's syndrome which then complicated by gallstone ileus. She was found to have several large stones causing her small bowel obstruction. Treatment options are endoscopic, open surgery or laparoscopic removal of the stones.

An Unexpected Cause of Intestinal Obstruction in an Uncommon Site

Question: A 77-year-old man, with an unremarkable clinical history, was referred to the emergency room for intermittent abdominal pain and vomiting for 2 weeks. Plain abdominal radiography was negative. Abdominal ultrasonography revealed a retracted gallbladder filled with biliary sludge and large (>3 cm) stones. Abdominal CT confirmed these findings and showed pneumobilia and air in the gallbladder, as well as edema of the duodenal wall. Because this last CT feature was not clear, a MRI was performed, which showed the presence of a cholecystoduodenal fistula (Figure A). No other radiologic abnormalities were observed. Upper gastrointestinal (GI) endoscopy confirmed the presence of a 10 mm duodenal fistula on the anterior wall of the duodenal bulb (Figure B). The patient underwent laparoscopy, converted to open surgery, with closure of the fistula and removal of the gallbladder. No other abdominal abnormalities were observed during surgery. Intraoperative cholangiography showed no stones in the biliary tree. Three days later, the patient manifested clinical features of acute intestinal obstruction characterized by abdominal pain, vomiting, bowel closed to feces and flatus, and abdominal distention. An abdominal CT was ordered. What could it be? What is the appropriate management? Look on page 305 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT showed distention of the small and large intestine up to the sigmoid colon, where was evident a large biliary stone of nearly 3.5 cm impacted in a segment of diverticular disease (Figure C). These findings are typical for gallstone coleus.1Lassandro F. Gagliardi N. Scuderi M. et al.Gallstone ileus analysis of radiological findings in 27 patients.Eur J Radiol. 2004; 50: 23-29Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar Because the first CT/MRI were negative for ectopic gallstones, it can be hypothesized that the stone migrated in the time interval between these exams and the surgical intervention. Gallstone obstruction caused by the impaction of large (>25 mm) biliary stones in the GI tract accounts for 1%-3% of cases of intestinal obstruction. Gallstones coleus accounts for 4% of cases of gallstone obstruction.2Reisner R.M. Cohen J.R. Gallstone ileus: a review of 1001 reported cases.Am Surg. 1994; 60: 441-446PubMed Google Scholar The stones impact where the lumen is narrowed by malignancy, diverticular disease, or radiation therapy. Gallstone coleus most frequently results from cholecystocolonic fistula, although it is much rarer in cases of cholecystoduodenal fistula, because the usual site of obstruction in this case is the terminal ileum or the ileocecal valve. Surgery has been advocated as the treatment of choice. It is however plagued by significant morbidity and mortality.2Reisner R.M. Cohen J.R. Gallstone ileus: a review of 1001 reported cases.Am Surg. 1994; 60: 441-446PubMed Google Scholar Alternative endoscopic approaches, such as basket removal or electrohydraulic lithotripsy, have occasionally been described in case reports.3Zielinski M.D. Ferreira L.E. Baron T.H. Successful endoscopic treatment of colonic gallstone ileus using electrohydraulic lithotripsy.World J Gastroenterol. 2010; 16: 1533-1536Crossref PubMed Scopus (27) Google Scholar Our patient underwent urgent colonoscopy. An initial attempt of stone removal with a Dormia basket (Web extraction basket, Wilson-Cook Medical Inc.) proved unsuccessful, because the stone was tenaciously impacted (Figure D). An attempt of mechanical lithotripsy (BML 4Q, Olympus; Fusion Lithotripsy Basket, Wilson-Cook Medical) also failed because of the hardness of the stone and fracture of the Dormia basket (Figure E). Holmium laser lithotripsy (VersaPulse PowerSuite 100W, Lumenis Surgical), commonly used in urology, was used to partially fracture the stone (Figure F). A thin (200 μm), flexible laser fiber which generated a power of 10 Watt, was used. After partial fragmentation the stone was recaptured with another Dormia basket and pulled out of the colon (Figure G). The patient clinically improved in the successive days. Subsequent CTs showed marked reduction in intestinal distention, without the presence of other biliary stones (Figure H). At 4 months of follow-up the patient remains asymptomatic. To our knowledge, this is the first report of a combined endoscopic-laser lithotripsy approach to gallstone coleus. Moreover, here we report the first MRIs of a cholecystoduodenal fistula. In such a context, MRI seems to perform as well as, or even better than, CT, which is considered the gold standard.1Lassandro F. Gagliardi N. Scuderi M. et al.Gallstone ileus analysis of radiological findings in 27 patients.Eur J Radiol. 2004; 50: 23-29Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar Finally, this case underlies the need for meticulous systematic search for ectopic gallstones when surgery is performed for cholecystoduodenal fistula, even though there are no signs of their passage through the fistula at the moment of surgery.

Unexpected Cause of Acute Recurrent Vomiting

Question: A 70-year-old woman who was visiting our city presented to the emergency department with a 24-hour history of nausea, voluminous, recurrent vomiting, and epigastric pain. Medical history disclosed gastroesophageal reflux disease, osteoporosis, and chronic cognitive impairment. There was no antecedent of trauma or surgical interventions. She was taking omeprazole and raloxifene hydrochloride as regular medications. At presentation, vital signs were unexceptional and she did not look seriously ill. On examination her abdomen was soft, nontender, and without palpable masses. Laboratory testing was notable for a white blood cell count of 11,300/mm3, erythrocyte sedimentation rate and renal function parameters being within normal limits. Chest radiography displayed no subdiaphragmatic free air but a plain abdominal x-ray demonstrated a significant abnormality (Figure A). What is the diagnosis? Look on page 1223 for the answer and see the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. Plain abdominal x-ray at admission revealed air in the theoretical localization of the biliary tree and paucity of intestinal gas. In view of the history and these radiographic findings, a computed tomography (CT) was requested. Abdominal CT (Figure B; medial view; Figure C, axial view) showed the classic Rigler’s triad of pneumobilia (small black arrows), ectopic gallstone (white arrow), and bowel obstruction, which is specific for gallstone ileus. A cholecystoduodenal fistula (large black arrow), gastric distension, and pericholecystic inflammatory changes could also be appreciated. Because the gallstone was impacted into the second part of the duodenum, a diagnosis of Bouveret’s syndrome was established. After early conservative management, the patient’s relatives asked us for permission to transfer her to their reference center. Once there and while discussing about the most appropriate therapeutic procedure to be performed, the gallstone (4 cm in size) was surprisingly eliminated with feces (Figure D) and she was discharged asymptomatic without need of surgical intervention. Throughout the following year, she has remained symptom free. Leon Bouveret described in 1896 the two first patients with gastric outlet obstruction caused by impacted gallstones into the duodenum after passage through a cholecystoduodenal fistula.1Bouveret L. Stenose du pylore adherent à la vesicule.Rev Med (Paris). 1896; 16: 1-16Google Scholar Risks factors for this uncommon form of gallstone ileus are female sex, advanced age (>60 years), long history of cholelithiasis, recurrent cholecystitis, and large size of the calculi.2Mavroeidis V.K. Matthioudakis D.I. Economou N.K. et al.Bouveret syndrome—the rarest variant of gallstone ileus: a case report and literature review.Case Rep Surgery. 2013; 2013: 839370PubMed Google Scholar, 3Cappell M.S. Davis M. Characterization of Bouveret’s syndrome: a comprehensive review of 128 cases.Am J Gastroenterol. 2006; 101: 2139-2146Crossref PubMed Scopus (124) Google Scholar In this context, minimally invasive treatment, such as endoscopic retrieval or lithotripsy, has a rather low success rate.3Cappell M.S. Davis M. Characterization of Bouveret’s syndrome: a comprehensive review of 128 cases.Am J Gastroenterol. 2006; 101: 2139-2146Crossref PubMed Scopus (124) Google Scholar Although enterolithotomy or gastrostomy, with or without cholecystectomy and fistula repair, are the most common therapeutic approaches, spontaneous resolution can exceptionally occur.3Cappell M.S. Davis M. Characterization of Bouveret’s syndrome: a comprehensive review of 128 cases.Am J Gastroenterol. 2006; 101: 2139-2146Crossref PubMed Scopus (124) Google Scholar

Successful Endoscopic Management of Bouveret’s Syndrome: A Rare Cause of Duodenal Obstruction

Introduction: Bouveret’s syndrome is gastric outlet obstruction caused by a gallstone impacted in the proximal duodenum or pylorus. Endoscopic management is the preferred approach in these patients. We report one such case, which was successfully managed endoscopically. Case Report: An 82-year-old male with history of dementia, heart failure, and atrial fibrillation presented with 3 days of nausea, vomiting, and inability to tolerate per oral intake. He was tachycardic, dehydrated, and had a slightly distended but non-tender abdomen with hypoactive bowel sounds. Abdominal x-ray revealed nonobstructive bowel gas pattern with linear branching lucencies overlying the left hepatic lobe consistent with pneumobilia. CT scan revealed gastric outlet obstruction due to a large gallstone. Given the patient’s multiple comorbidities and age, he was deemed to be a poor surgical candidate and was referred for endoscopic evaluation and management. At endoscopy, a large gallstone occupying the entire lumen of the duodenal bulb was seen. The stone was fragmented using electrohydraulic lithotripsy. A rat tooth forceps and a stone retrieval basket were used to remove the larger pieces of the stone from the stomach. Upon complete removal of the stone, no evidence of a gross biliary-enteric fistula was found. Patient did well post procedure and was discharged home. Discussion: A rare complication of gallstones is formation of a cholecystoduodenal fistula, which can lead to passage of stones into the small bowel causing what is known as gallstone ileus. In 1-3% of these cases, the gallstone can be lodged in the duodenum causing gastric outlet obstruction, which is known as Bouveret’s syndrome. It is most commonly seen in elderly women. Clinical presentation can be nonspecific. Imaging with CT/MRI can reveal the Rigler’s triad of pneumobilia, bowel obstruction and ectopic gallstone. Early diagnosis is key since mortality can be high in this condition, reportedly between 12% and 33%. Endoscopic management has been well described in the literature and is the preferred therapeutic option. Fragmentation of the stone can be performed endoscopically with mechanical, electrohydraulic, or laser lithotripsy. Surgery is often not pursued, as these patients are usually poor surgical candidates such as in our case. Surgery, however, may still be needed for patients with impaction of the gallstone more distally in the small bowel. Conclusion: Endoscopic management of Bouveret’s syndrome should be considered a first line option, especially in an elderly patient with multiple medical comorbidities. Electrohydraulic lithotripsy is a safe and highly effective modality for managing this challenging endoscopic entity.

Acute abdomen in a septuagenarian

A 72-year-old lady presented with abdominal pain and distention of 3 days duration. She did not pass flatus and stools and had few episodes of bilious vomiting for 2 days. She had no past history of abdominal pain or surgery. Coronal CT scan section of abdomen (Fig. 1) showed classical Rigler’s triad of pneumobilia, dilatation of small bowel loops and ectopic gallstone which is characteristic of gallstone ileus [1]. At surgery, the stone was 6 cm × 4 cm in size without any facets. The obstruction was at the midjejunal level. Often gallstones causing gallstone ileus enter the bowel through cholecystoduodenal fistula. Management is mainly surgical enterolithotomy. During surgery the finding of facets in the retrieved gallstones may indicate presence of other stones. Due to the emergent nature, patient’s old age and the complex mass involving the gallbladder and the cholecystoduodenal fistula cholecystectomy and fistula repair can be done at a later date once the patient recovers. Nearly 17% of them present with recurrent gallstone ileus or other biliary complications [2]. Hence interval cholecystectomy and fistula repair is prudent. Other treatment option is enteroscopic removal.

Ultrasound and MR identification of ectopic gallstones as a complication of laparoscopic cholecystectomy

A 23 year old female underwent laparoscopic cholecystectomy complicated by gallstone and biliary spillage into the peritoneal cavity. Six years after surgery, ectopic gallstones were identified in the pelvis on sonography and MR imaging. Identification of ectopic gallstones is imperative for the expeditious diagnosis of the etiology and cause of the patient's symptoms prior to the development of more severe complications. Clinical sequelae of dropped gallstones include abscess formation, empyema, intra-abdominal adhesions, and draining sinus formation. Delay in diagnosis and treatment is often due to lack of awareness of intraoperative events and potential complications, unusual presentation of symptoms, and unexpected site of infection.

Laparoscopic Enterolithotomy Is a Valid Option to Treat Gallstone Ileus

Gallstone ileus is a well-recognized clinical entity. It usually affects elderly female patients, and very often diagnosis can be delayed resulting in high morbidity and mortality. An abdominal x-ray and computed tomographic (CT) scan of the abdomen may show classical radiological features of small bowel obstruction, pneumobilia, and an ectopic gallstone. Laparotomy and enterlithotomy with or without definite biliary surgery is an established treatment. Since 1992, many cases of laparoscopic-assisted enterolithotomy have been reported. Only a few cases of a totally laparoscopic approach have been documented. We present the case of a 75-year-old lady who presented with features of intestinal obstruction. A plain x-ray of the abdomen and a CT scan confirmed the classical features of gallstone ileus. A totally laparoscopic enterolithotomy was performed using 6 ports. A 6-cm gallstone was retrieved through a longitudinal enterotomy. The transverse closure of the enterotomy was performed with intracorporeal suturing, resulting in an uneventful postoperative recovery. We suggest that a CT scan helps in the early diagnosis of the cause of intestinal obstruction, and totally laparoscopic enterolithomy with intracorporeal enterotomy repair is a valid, safe option.