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.