PMC9909495_01
Preoperative abdominal X-ray showed dilated loops with excessive gases.
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FIG1
The abdominal X-ray (AXR) showed dilated loops with excessive gases (Figure 1).
Fistula between the gallbladder and antrum. The white arrow shows the connection between the gallbladder and gastric antrum.
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FIG2
Abdominal computed tomography (CT) with intravenous (IV) and oral contrast revealed dense adhesion between hepatic flexure and gallbladder (GB), absence of GBS with mild wall thickening suggesting chronic cholecystitis, suspected fistulous communication between gallbladder and the antrum (Figures 2-3), pneumobilia (Figure 4), SBO at distal jejunum with transitional zoon.
Sagittal view of the fistula between the gallbladder and the antrum. The white arrow shows the connection between the gallbladder and the antrum.
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FIG3
Abdominal computed tomography (CT) with intravenous (IV) and oral contrast revealed dense adhesion between hepatic flexure and gallbladder (GB), absence of GBS with mild wall thickening suggesting chronic cholecystitis, suspected fistulous communication between gallbladder and the antrum (Figures 2-3), pneumobilia (Figure 4), SBO at distal jejunum with transitional zoon.
CT abdomen showing pneumobilia. The arrow points to the air in the intrahepatic biliary tree.
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FIG4
Abdominal computed tomography (CT) with intravenous (IV) and oral contrast revealed dense adhesion between hepatic flexure and gallbladder (GB), absence of GBS with mild wall thickening suggesting chronic cholecystitis, suspected fistulous communication between gallbladder and the antrum (Figures 2-3), pneumobilia (Figure 4), SBO at distal jejunum with transitional zoon.
CT abdomen. The arrow shows the Mercedes Benz sign with the proximal bowel loop dilated and collapsed distal loops.
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FIG5
This SBO was found to be secondary to impacted 18 mm single GBS which contains fissures filled with fluid and air which are arranged in a pattern resembling the Mercedes Benz sign (Figure 5), which presents in 50% of GBS cases.
Upper endoscopy. The upper panel (A) shows the bilious secretions and the lower panel (B) shows the gallbladder stone at the second part of the duodenum.
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FIG6
An upper gastrointestinal endoscopy was done and showed competent cardia with bilious greenish secretions filling the stomach, normal gastric mucosa, and pylorus (Figure 6).
Upper endoscopic view. The upper panel (A) shows normal gastric mucosa D2; in the lower panel (A) the arrow shows the ulcer at the first part of the duodenum.
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FIG7
The findings from the duodenum (D1) were the anterio-inferior wall ulcer of clean base 1 cm size (Figure 7), normal D2-D3, and the gallbladder stone retrieved from D2 by biopsy basket size of 1.5 cm.
Gallstone retrieved from the jejunum
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FIG8
Intraoperatively, a 3 cm GBS stone was found obstructing the distal jejunum (Figure 8).