PMC6794980_01
ERCP shows multiple stones in the common bile duct (red arrow).
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A forty nine-year-old female presented to the emergency department due to episodes of sudden cramping, epigastric pain and nausea 2 months following endoscopic retrograde cholangiopancreatography (ERCP) where three gallstones were removed from the common bile ducts (Figure 1).
Abdominal ultrasound depicting a large stone in the gallbladder (red arrow).
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Before she underwent ERCP and endoscopic sphincterotomy, right upper quadrant abdominal ultrasound done on account of obstructive jaundice showed a noninflammed gallbladder with a large stone and a dilated common bile duct (Figure 2).
Contrast CT scan depicting gallstone in bowel (short red arrow).
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At presentation, her abdominal computed tomography (CT) revealed evidence of small bowel obstruction with clear evidence of gallstone ileus (Figure 3). A large, calcified 3.5 cm x 3 cm gallstone was found in the small bowel impacted at 60 cm proximal to the ileocecal valve (Figure 3) with evidence of pressure necrosis to the bowel.
Contrast CT scan depicting cholecystoduodenal fistula (short red arrow).
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A cholecystoduodenal fistula was also present (Figure 4).
CT contrast scan depicting decompressed GB and air in GB, verifying that a stone was released (short red arrow).
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Evidence of a decompressed gallbladder (Figure 5) and a clear transition point were noted.
CT contrast scan depicting bowel anastomosis after 1st surgery (short red arrow).
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The segment that had the stone was identified and exteriorized through a small midline incision; the bowel was necrotic due to pressure ischemia; thus segmental bowel resection was performed with stapled anastomosis (Figure 6).
CT contrast scan depicting free air in pocket of abscess where bowel was perforated (short red arrow).
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PE, but positive for free air (Figure 7). Patient was taken back to the OR for laparotomy, which revealed a second large non-calcified gallstone in the ileum impacted at the ileocecal valve distal to the previous anastomosis and perforated necrotic small bowel with a pocket of abscess.