Presentation
The patient presents to the emergency department with complaints of feeling dizzy and a sensation of impending loss of consciousness. No abdominal pain. He reports having had intermittent episodes of vomiting for several months.
Patient Data
The gallbladder is distended and filled with gallstones, hindering proper assessment. Thickened walls, which show an edematous appearance. There are no definite signs of peri vesicular inflammation. Negative sonographic Murphy's sign.
The gallbladder demonstrates extensive inflammatory changes with a thick and irregular wall. Heterogeneous gallbladder content, including several images suggestive of gallstones and gas. There is a 2 cm communication defect between the gallbladder and the second portion of the duodenum, which appears dilated and contains also some gallstones. Mild inflammatory changes are noted in the adjacent fat.
Findings are suggestive of a cholecystoduodenal fistula.
Secondary intra and extrahepatic aerobilia. Mild reactive periportal edema.
Left pleural thickening with multiple focal pleural calcifications and moderate pleural effusion showing an organized appearance.
Case Discussion
An esophagogastroduodenoscopy was conducted several hours after CT, showing three large post-pyloric stones. The most distal one was impacted in the duodenum and could not be surpassed. An attempt was made to extract them using a loop, but it was impossible due to their size. The duodenal wall showed ulceration, and due to a high risk of perforation, lithotripsy was ruled out.
Surgery was performed via laparotomy the same day, carrying out a prepyloric gastrostomy and extraction of the gallstones. The patient progressed favourably with antibiotic treatment and was discharged after 4 days.
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