PMC2239211_01
Computed tomography (CT) scan of abdomen and pelvis. (a) Axial image showing pneumobilia (arrow) and a dilated fluid-filled stomach (). (b) 1-2 large gallstones (arrow) can be seen within an area of inflammation
where the gallbladder is in close proximity to the duodenum. (c) Coronal reconstruction showing gallstone within duodenum (long arrow), Pneumobilia (short arrows), and dilated stomach () are also seen.
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fig1
A CT scan (see Figure 1) showed a markedly distended stomach, air in the biliary tree, and a thickened gallbladder containing one or two large gallstones, the largest  cm in size, which appeared to be abutting the duodenal wall in an area of significant inflammation.
(a) large gallstone in the duodenal bulb, obstructing the pylorus. (b) Attempts to extract the stone failed with multiple instruments, including biliary and CRE balloons (). The orifice of the choledochoduodenal fistula (arrow) can be seen.
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fig2
Endoscopy demonstrated old blood in a distended stomach, and a large gallstone in the duodenal bulb obstructing the pylorus (see Figure 2(a)). The position of the gallstone, the surrounding ulcerated mucosa, and the size of the fistula's orifice made attempts to extraction difficult despite the use of grasping forceps, jumbo biopsy forceps, different-sized and shaped snares, retrieval baskets and nets, as well as biliary balloons and controlled radial expansion (CRE) balloons (see Figure 2(b)).
Two different lithotripters were used to fragment the stone. (a) Holmium: YAG laser produced small cracks on the proximal surface (arrows) but the majority of the stone still remained impacted. (b) Electrohydraulic lithotripsy (IEHL) successfully shattered the outer "shell" of the stone (white arrow) and left behind a smaller, much harder core (black arrow). (c) Ultimately, the majority of the stone was fragmented after extensive use of both lithotriptors.
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fig3
USA), and constant sterile water irrigation was infused through the second channel. Using a total of 3840 joules, 3917 pulses per second for a total time of 7 minutes and 27 seconds, the laser successfully produced small cracks in the stone and ultimately fragmented the proximal portion (see Figure 3(a)); however, the procedure was terminated due to rapid atrial fibrillation and long procedure time. Using a 1.9F fiber (power of 1, increased to 40; frequency of 10, increased to 30) under constant saline irrigation, IEHL was successful at shattering the outer "shell" of the stone and breaking it into two large pieces, leaving behind an extremely hard, smaller core (see Figure 3(b)). Ultimately, the majority of the stone was fragmented (Figure 3(c)) though the larger piece still could not be removed easily from the duodenal bulb. Using a "double-snare" technique, two jumbo polypectomy snares ( cm, Cook
Double-snare extraction technique. Two overlapping jumbo polypectomy snares 
(arrows) were used to grasp the stone at different angles, providing adequate leverage for extraction into the stomach.
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fig4
Endoscopy, Ind, USA) were used to grasp the still-impacted large stone fragment at different angles and pull it into the stomach (see Figure 4). Examination of the remainder of the duodenum showed no other stones.
Visualization of the choledochoduodenal fistula. (a) After stone extraction, the large orifice
of the fistula (arrow) can be seen in the duodenal bulb, whose mucosa is diffusely ulcerated. (b) The gastroscope passed easily through the fistula into the lumen of the gallbladder.
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fig5
The large cholecystoduodenal fistula was visualized, and the gastroscope easily passed into the lumen of the gallbladder (see Figure 5).
The largest stone fragments were removed perorally. The inner composition of the largest piece
can be seen, measuring greater than 1 cm in diameter.
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fig6
The larger fragments were removed perorally (see Figure 6) with a Roth net (US Endoscopy, Ohio, USA), while the very small pieces were left behind to pass spontaneously.