Presentation
Nausea, vomiting, and upper abdominal pain for several days.
Patient Data
Pneumobilia.
Wall thickening of the gallbladder with fistulous communication to duodenum. No calcified gallstones visualized.
Dilated loops of proximal small bowel with decompressed distal small bowel, no well-defined transition point. No calcification of the bowel identified.
Other findings: Scattered diverticula of the colon without evidence of acute diverticulitis. Osteoarthritic changes to the hips.
The patient was subsequently admitted from the ED and followed by surgery for partial small bowel obstruction. A small bowel follow-thru was performed to monitor.
A small bowel series was performed to monitor this patient's bowel obstruction. Seen on the 22 hour image, there is residual contrast within the duodenum and an extraluminal collection superiorly. Additionally, contrast can be identified within a mildly dilated common bile duct. On comparing this study to the patient's CT, these findings are suspicious for cholecystoduodenal fistula.
Of note at 34 hours, there is a filling defect present within an ileal loop.
Approximately 48 hours after being admitted, the patient's condition began to improve without surgical intervention. The stone was not visualized in the patient's stool, but is presumed to have passed spontaneously.
Case Discussion
This patient had typical findings of gallstone ileus including pneumobilia, cholecystoduodenal fistula, and partial small-bowel obstruction. Notably, no calcified gallstone was identified but radiolucent gallstone was the most likely cause of bowel obstruction in this patient given evidence of cholecystoduodenal fistula and filling defect within the ileum on small bowel follow-thru.
Most patients require surgical management for gallstone ileus, but this patient spontaneously improved with likely passing of the stone through the stool. In such cases, surgical correction of the cholecystoduodenal fistula may not be necessary as they may spontaneously resolve and decision for definitive surgical management should be individualized on follow up of patient symptoms and anesthesia risk.
Unable to process the form. Check for errors and try again.