PMC7484525_01
(A, B) Gallstone seen on gastroscopy and mistaken for a necrotic budding aspect of the duodenal wall. (C) Biopsy taken to rule out pancreatic neoplasia invading the duodenum.
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An EGD performed showing a bulky gastric liquid content of more than five liters, suctioned and followed by advancement to duodenum, where distorted appearance of the duodenal bulb and duodenum were noted, with deep and necrotic ulcerations in place as well as a budding aspect of the wall (Fig. 1A and B). No sign of malignancy (Fig. 1C).
(A) Aerobilia as seen on axial CT scan. (B) Axial view CT showing dilated stomach and duodenum with a 17 mm stone at the level of D2-D3. (C) Sagittal view CT showing dilated stomach and duodenum with a 17 mm stone at the level of D2-D3 (arrow).
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Naso-Gastric tube was inserted, An Oral-enhanced abdominal CT Scan was done and showed the presence of aerobilia with air inside the gallbladder and a fistulous tract between the gallbladder and the duodenal bulb associated with a calculi of 17 mm (Fig. 2A-C). no other abnormal findings were noted.
KUB showing aerobilia.
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KUB X-ray was also performed showing colic opacification and the presence of the aerobilia (Fig. 3).
Opening of the fistulous tract (Suction: towards the pylorus, Metzenbaum Scissors: towards distal duodenum).
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Identification and opening of the fistulous tract between the gallbladder and the duodenum D1 and palpation of the impacted stones in second part of duodenum (Fig. 4).
Identification of a gallstone (Arrow) post widening of the fistula opening to a diameter of 5 cm.
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Kocher maneuver done, followed by duodenotomy that widen the fistulae opening (Fig. 5).
Two removed gallstones of 2 x 2 x 1 cm and 6 x 3.5 x 3 cm.
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Identification and removal by proximal milking of the first 2 x 2 x 1 cm gallstone, followed by the removal of another bigger one of 6 x 3.5 x 3 cm (Fig. 6).
Gastrojejunal anastomosis (White arrow: efferent jejunal limb, Grey arrow: Afferent Jejunal limb, Right/Left Gold Arrow: extent of large gastrojejunal anastomosis).
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Treitz angle (Fig. 7) and selective vagotomy performed. This surgical approach was described in literature without changes.