PMC9857250_01
Coronal section computed tomogram showing a calcified gallstone in the proximal duodenum (black asterisk), distended stomach (white asterisks), and pneumobilia (white arrows) concerning for a cholecystoduodenal fistula with the Bouveret syndrome.
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F1
Computed tomography (CT) of the abdomen and pelvis showed features concerning for acute-on-chronic cholecystitis, a 26 mm calcified gallstone in the proximal duodenum, and pneumobilia suggestive of a cholecystoduodenal fistula with Bouveret syndrome (Figure 1).
Esophagogastroduodenoscopy findings. (A) Large gallstone impacted in the distal duodenal bulb with a cholecystoduodenal fistula (white arrow) immediately proximal to the stone. (B) The stone pulled into the stomach with a web basket. (C) Postmechanical lithotripsy. (D) Stone fragments being extracted with the use of Roth nets. (E) Postextraction image of the duodenal bulb showing the cholecystoduodenal fistula (white arrow) draining bile into a clear duodenal lumen.
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F2
Under constant traction, the gallstone was brought out into the stomach, where a series of mechanical lithotripsy was performed under endoscopic guidance until the stone fragments were small enough to be extracted with the use of Roth nets (Figure 2).
PMC9857250_02
Coronal section computed tomogram of the abdomen and pelvis showed marked distension of the stomach, pneumobilia (white arrows), and an obstructing 40 mm calcified gallstone in the duodenal bulb (black asterisk). This is the Rigler triad that is considered pathognomonic for the Bouveret syndrome.
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F3
CT of the abdomen and pelvis showed marked distension of the stomach, gallbladder wall thickening and mucosal hyperenhancement with cholelithiasis, extensive intrahepatic and extrahepatic pneumobilia, biliary mucosal hyperenhancement, and an obstructing 40 mm calcified gallstone in the duodenal bulb (Figure 3).
PMC9857250_03
Axial section computed tomogram of the abdomen showing an ill-defined necrotic mass (white asterisk) in the gallbladder fossa of the liver in direct fistulous communication with the transverse colon (white arrow).
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F4
CT of the abdomen and pelvis with intravenous contrast showed an ill-defined necrotic mass in the gallbladder fossa of the liver in direct fistulous communication with the transverse colon measuring 6.0 x 7.0 cm (Figure 4).
Axial section computed tomogram of the abdomen showing mesenteric nodularity and thickening (white arrows) concerning for omental carcinomatosis.
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F5
Also noted was mesenteric nodularity and thickening concerning for omental carcinomatosis in the anterior mesentery (Figure 5).
Colonoscopy showing a large ulceration with heaped up edges in the hepatic flexure. The base of the ulcer seemed to tunnel representing the fistula (white arrow) to the gallbladder.
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F6
The base of the ulcer seemed to tunnel, which represented the known fistula to the gallbladder (Figure 6).