Like a “Rolling” Gallstone: Cholecystoduodenal Fistula as Evidence of Gallstone Ileus

Excerpt

A 91-year-old East Asian woman was evaluated in the Emergency Department with symptoms of left flank pain, nausea, and vomiting. She was awakened at 4 a.m. with the sudden onset of these symptoms for which she applied a fentanyl pain patch with pain relief. Physical examination was unremarkable. Past medical history was significant for depression, hyperlipidemia, and hypertension. The patient had undergone a negative exploratory laparotomy many years ago for unclear reasons. Laboratory studies including liver panel and complete blood count were unremarkable. Initial CT scan of the abdomen showed a nondistended but thick-walled gallbladder with pericholecystic edema and possible gallstones with pneumobilia. Upper endoscopy revealed an ulcerated area with a fistulous opening containing a pigment stone in the first portion of the duodenum (Fig. 1). Endoscopic ultrasound findings included a thickened gallbladder wall with a fistulous opening in the duodenum consistent with cholecystoduodenal fistula (Fig. 2). The patient was managed conservatively with bowel rest and intravenous hydration. Over the course of the next few days, she had recurrent symptoms of left-sided abdominal pain, associated with nausea and vomiting. Repeat CT scan demonstrated signs of small bowel obstruction, pneumobilia, and an impacted stone in the jejunum, consistent with Rigler’s triad (Fig. 3). Laparoscopic-assisted enterotomy was able to successfully remove the obstructing pigment intraluminal gallstone, which measured 3.8 cm (Fig. 4). She did well and was discharged home 6 days later; 1 week later, she denied any symptoms during routine follow-up visit. The patient was offered the option of cholecystectomy or endoscopic therapy for residual gallstones, but after some discussion with her family, these options were not pursued.

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