Cholecystoduodenal fistula due to calculous cholecystitis with gallstone migration
Diagnosis certain
Presentation
Right upper quadrant pain, prior US confirmed calculous cholcystitis, which was managed conservatively. Worsening abdominal distension, repeat US shows small bowel distension, potential ileus.
Patient Data
Age: 80 years
Gender: Female
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Major findings:
- Contracted gallbladder with wall hyperenhancement and foci of intraluminal air (also in the CBD and intrahepatic bile ducts), and focal fat stranding. The wall is attached to the duoudenum, suggestive of fistulization.
- Inhomogeneous arterial phase hyperenhancement of the liver adjacent to the gallbladder fossa, likely inflammatory.
- About 30 mm egg-shaped low density structure in the rectum, likely the migrated known gallstone (confirmed clinically later on).
- Distended small bowel with air-fluid levels indicative of stasis, but no bona fide SBO.
Other findings:
- Left adrenal mass, potential adenoma, further characterization with adrenal protocol multiphase CT warranted.
- Simple renal cysts, perirenal fat stranding, right lower polar accessory artery.
- Small hiatal hernia.
- Mutiple calcified subcutaneous soft tissue granulomas
- Diverticulosis
Case Discussion
Findings are in line with cholecystoduodenal fistulization caused by prolonged calculous cholecystititis. This lead to a migration of the gallstone with resultant subileus, however no definitive SBO could develop before the stone eventually reached the rectum, from which it was evacuated shortly after the exam.
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