Main Text
An 85-year-old man presented to Emergency Department with a history of
epigastric pain and vomiting for 2 days. On physical examination, his
abdomen was distended and painful to palpation. Laboratory findings
showed raised inflammatory markers.
Plain abdominal radiograph (Figure 1) showed gastric distension with
air-fluid level, pneumobilia and an ectopic calcified gallstone in the
lower right quadrant. This represents the Rigler triad, suggesting
gallstone ileus. Contrast-enhanced CT (Figure 2) revealed marked gastric
distension and stasis conditioned by a 4cm gallstone in the level D3 of
duodenum. CT also showed cholelithiasis and a
cholecystoduodenal fistula. In addition to pneumobilia, there was also
pneumoportia and associated pneumatosis of the gastric wall, suggesting
ischemia due to acute massive distension. Subsequently, the patient was
submitted to open entero-lithotomy, but died 13 days later.
Bouveret syndrome is a rare subset of gallstone ileus that presents with
gastric outlet obstruction secondary to impaction of a gallstone in the
pylorus or proximal duodenum, via an acquired cholecystoenteric
fistula1. In addition to the Rigler triad, CT can also
depict the fistula, number and location of the gallstones, status of the
gallbladder, level and degree of obstruction and signs of ischemia, that
are important factors for the treatment decision2.