An authentic radiological triad of Rigler allowing the diagnosis of gallstone ileus: A case report.

The Rigler's Triad consists by three radiological signs, including intestinal obstruction, pneumobilia, and an aberrant gallstone in the bowel. It is an inconstant triad considered being pathognomonic of gallstone ileus. Gallstone ileus is an exceptional complication of cholelithiasis due to the passage of one or more gallstones from the bile ducts into the lumen of the bowel through a biliodigestive fistula. We report the case of an 83-year-old female patient with a history of ischemic heart disease and an asymptomatic large gallstone. The patient was admitted to the emergency department for bowel obstruction, abdominal pain, and bilious vomiting. A clinical examination found a patient with an alteration in general condition and a distended abdomen with tenderness. An abdominal CT scan revealed Rigler's triad, allowing the diagnosis of gallstone ileus. A midline exploratory laparotomy was performed to find a giant gallstone blocked in the last ileum loop. A simple enterolithotomy was performed, allowing the extraction of giant lithiasis from an 8-cm major axis. The postoperative evolution was uneventful, and the patient was discharged 4 days after surgical treatment.

Imaging diagnosis of a rare case of intermittent intestinal pneumatosis: A consequence of ileocecal valve clip dysfunction?

Pneumatosis intestinalis is a condition characterized by the presence of gas or air pockets within the walls of the intestines. It can occur in any section of the gastrointestinal tract but it is most commonly found in the colon. Etiology and pathogenesis of PI are not yet fully understood, but several potential factors have been suggested to play a pivotal role in the development of this pathologic condition. Pneumatosis intestinalis seems to arise from a complex interplay between various factors, such as the integrity of the intestinal lining, pressure within the portal vein, the composition of the microbiological flora in the gut. Pneumatosis intestinalis can be caused by a variety of underlying conditions, such as bowel obstruction, intestinal ischemia, infection, inflammatory bowel disease, or certain medications. Symptoms may include abdominal pain, bloating, diarrhea, vomiting, and bloody stools. We present a case report of a 63-year-old male patient who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis with recurrent cholecystitis. Following the surgery, the patient experienced a rapid drop in hemoglobin levels, necessitating an urgency regimen laparoscopic abdominal exploration which revealed Meckel's diverticulitis with active bleeding leading to diverticulectomy. The next day, the patient developed a radiological condition characterized by the co-presence of intermittent pneumatosis intestinalis, Portal pneumatosis and intermittent small bowel obstruction.

Gastric Outlet Obstruction Caused by Complicated Cholelithiasis: Bouveret Syndrome.

Teaching Point: Bouveret syndrome can be diagnosed on plain film, ultrasound, computed tomography and magnetic resonance imaging by demonstrating Rigler's triad which includes a dilated stomach, pneumobilia, and ectopic gallstone.

Mechanical Small Bowel Obstruction Due to Gallstone Ileus: Diagnostic Challenges and Surgical Management.

Gallstone ileus is a true mechanical intestinal obstruction. It is caused by gallstone impaction in the gastrointestinal (GI) tract after eroding and passing through a bilioenteric fistula. Gallstones are frequently impacted in the terminal ileum. Computed tomography (CT) imaging is diagnostic and shows specific findings of dilated small bowel loops suggesting small bowel obstruction, pneumobilia, and impacted gallstone in the small bowel. Favorable outcome is achieved by having strong clinical suspicion, timely diagnosis, preoperative resuscitation, and early surgical intervention. The three available surgical procedures to relieve gallstone ileus are entrolithotomy alone; one-stage procedure of enterolithotomy, cholecystectomy, and fistula closure; or two-stage procedure of enterolithotomy followed by cholecystectomy. This article outlines the clinical presentation, diagnosis, resuscitation, and different surgical interventions of patients with gallstone ileus.

Sphincter of Oddi incompetence associated with duodenal stenosis in a newborn: A case report.

Newborn incompetence of the sphincter of Oddi is rare. While there are many causes of reflux of air or ingested contrast material into the biliary tree in adults, in the newborn, it is usually due to incompetence of the sphincter of Oddi associated with partial or complete duodenal obstruction. This paper presents upper gastrointestinal series findings of incompetence of the sphincter of Oddi associated with duodenal stenosis in a 3-day-old newborn. If pneumobilia is identified in the newborn, although the possibility is low, clinicians should consider incompetence of the sphincter of Oddi with duodenal obstruction as well as portal vein gas.

Endoscopic and surgical treatment of jejunal gallstone ileus caused by cholecystoduodenal fistula: A case report.

BACKGROUND: Gallstone ileus is a rare complication of gallstone disease in which a stone enters the enteric lumen and causes mechanical obstruction usually by bilioenteric fistula. Gallstone ileus accounts for 25% of all bowel obstructions among the population > 65 years of age. Despite medical advances over the last decades, gallstone ileus is still associated with high rates of morbidity and mortality. CASE SUMMARY: An 89-year-old man with a history of gallstones was admitted to the Gastroenterology Department of our hospital, complaining of vomiting and cessation of bowel movements and flatus. Abdominal computed tomography showed cholecystoduodenal fistula and upper jejunum obstruction due to gallstones, pneumatosis in the gallbladder, and pneumobilia indicating Rigler's triad. Considering the high risk of surgical management, we performed propulsive enteroscopy and laser lithotripsy twice to relieve the bowel occlusion. However, the intestinal obstruction was not relieved by the less invasive procedure. Then, the patient was transferred to the Department of Biliary-pancreatic Surgery. The patient underwent the one-stage procedure including laparoscopic duodenoplasty (fistula closure), cholecystectomy, enterolithotomy, and repair. After surgery, the patient presented with complications of acute renal failure, postoperative leak, acute diffuse peritonitis, septicopyemia, septic shock, and multiple organ failure, and finally died. CONCLUSION: Early surgical intervention is the mainstay of treatment for gallstone ileus. For elderly patients with significant comorbidities, enterolithotomy alone is advised.

Gallstone Ileus With Cholecystoenteric Fistula in an Elderly Female: A Case Report.

Mechanical small-bowel obstruction can occur due to various reasons, including the impaction of a gallstone in the ileum after it has passed through a cholecystoenteric fistula. Gallstone ileus is an infrequent yet significant cause of this condition. This case report documents an instance of gallstone ileus, which accounts for less than 1% of patients with mechanical small bowel obstruction. We report a 75-year-old female patient who presented with colicky pain in both upper quadrants, hyporexia, and constipation that worsened during a period of nine days, which subsequently was accompanied by nausea and vomiting of bilious appearance in the next three days. Abdominal CT reported a dilated common bile duct (1.7 cm) with multiple stones inside measuring between 5 and 8 mm associated with pneumobilia of intrahepatic bile ducts and dilatation of small intestinal loops produced by a high-density image of approximately 2.5 cm. Laparoscopic exploration showed an obstructive mass measuring 15 cm from the ileocecal valve corresponding to a 2.54 x 2.35 cm gallstone, which was removed and enterorrhaphy was performed. The sine qua non condition for gallstone ileus to occur is the presence of a fistula between the gallbladder and the gastrointestinal tract. The treatment is mainly surgical and should be aimed primarily at the intestinal obstruction and secondarily at the cholecystoenteric fistula. This condition tends to have a high rate of complications and consequently long hospital stays. Making a timely diagnosis provides us with the tools for a surgical approach aimed at intestinal obstruction and subsequently in the management of the biliary fistula.

Imaging of benign biliary pathologies.

Pathologies of the biliary tree include a wide-spectrum of benign and malignant processes. The differential for benign disease includes congenital and acquired disease with variable prognosis and management pathways. Given the ability to mimic malignancy, benign processes are difficult to diagnose by imaging. Direct cholangiography techniques with tissue sampling are the gold standards for the diagnosis of benign and malignant biliary pathologies. Non-invasive imaging with ultrasound offers a first-line diagnostic tool while MRI/MRCP offers higher specificity for identifying underlying pathology and distinguishing from malignant disease. In this review, we focus on the imaging appearance of dilatation, cystic anomalies obstruction, inflammation, ischemia, strictures, pneumobilia, and hemobilia to help construct a differential for benign processes.

A Rare Case of Cholecystoduodenal Fistula Complicated With Gallstone Ileus and Upper Gastrointestinal Bleeding.

Gallstone ileus is a rare presentation of cholelithiasis, which usually impacts the narrowest part of the bowel, the ileocecal valve. This occurs as a result of a bilioenteric fistula where a gallstone passed through and entered the gastrointestinal tract. It is most commonly encountered in elder patients and predominantly in females. Abdominal computed tomography is the investigation of choice for diagnosis in the majority of cases. Here, we present a 68-year-old female patient with a choledochoduodenal fistula complicated by upper gastrointestinal bleeding and gallstone ileus.

Laparoscopic management of cholecysto-duodenal fistula after spontaneous resolution of intestinal obstruction component of gallstone Ileus case report and literature review.

Gallstone ileus is a rare complication of gallstones and is a comparatively unique cause of intestinal obstruction. It involves the development of a cholecysto-enteric fistula through which a gallstone can pass into the gastrointestinal tract. Spontaneous resolution of intestinal obstruction in gallstone ileus is extremely rare. We report a 71-year-old patient who presented with right hypochondrial pain for four months. She had a three-day history of absolute constipation and abdominal distention two months before presentation that resolved spontaneously. Computed tomography revealed pneumobilia. Laparoscopic exploration showed a cholecysto-duodenal fistula that was divided, the opening in the first part duodenum was closed and cholecystectomy was completed successfully. The presence of pneumobilia in a patient with gallstones should raise the suspicion of bilio-enteric fistula. The obstruction component of gallstone ileus can resolve spontaneously in rare occasions. Single stage laparoscopic management of cholecysto-duodenal fistula is safe and feasible in the presence of an experienced laparoscopic surgeon.

Endoscopic Retrograde Cholangiopancreatography (ERCP): Used to Diagnose and Treat Cholecystoduodenal Fistula, a Rare Clinical Entity.

Biliary enteric fistula is a rare diagnosis. Common etiologies include chronic cholecystitis with cholelithiasis and peptic ulcer disease. Of these, the number one cause is chronic cholecystitis with cholelithiasis. Adhesion of a chronically inflamed gallbladder to the duodenum followed by erosion of the gallbladder wall by gallstones leads to the establishment of an abnormal communication between the gallbladder and duodenum. This abnormal communication, namely, cholecystoduodenal fistula, has a high mortality rate and therefore must be managed in a timely manner. The case presented in this report is that of a 76-year-old female suffering from chronic cholecystitis and cholelithiasis who was both diagnosed with as well as managed for cholecystoduodenal fistula by the use of endoscopic retrograde cholangiopancreatography (ERCP).

Spontaneous Pneumobilia: Not So Benign.

Pneumobilia is defined as air within the biliary system. It is usually caused by an abnormal connection between the biliary gastrointestinal tracts. Persistent asymptomatic pneumobilia is a rare occurrence and is generally considered a benign finding on imaging. Herein, we present a case of an 87-year-old male with long-standing pneumobilia of no identifiable cause who eventually developed Klebsiella cholangitis and bacteremia. In our report, we attempt to elucidate the causes of spontaneous pneumobilia and discuss its significance in the context of increased intraabdominal pressure.

Acute cholangitis detected ectopic ampulla of Vater in the antrum incidentally: A case report.

BACKGROUND: The ampulla of Vater is an opening at the confluence of the common bile duct and pancreatic duct. It is located in the second portion of the duodenum. An ectopic papilla of Vater is an anomalous termination. Few cases have been reported. We report the rare case of a man with an ectopic ampulla of Vater in the pylorus. CASE SUMMARY: An 82-year-old man had experienced abdominal pain and fever with chills 1 d before his presentation. A computed tomography scan of the abdomen demonstrated dilatation of the common bile duct approximately 2.2 cm in width. Gas retention was found in his intrahepatic ducts. Acute cholangitis with pneumobilia was identified, and he was hospitalized. Esophagogastroduo-denoscopy and endoscopic retrograde cholangiopancreatography disclosed no ampulla of Vater in the second portion of the duodenum. Moreover, a capsule-like foreign body (pharmaceutical desiccant) approximately 1 cm × 2 cm in size was found at the gastric antrum and peri-pyloric region. After the foreign body was removed, one orifice presented over the pyloric ring in the stomach, a suspected ectopic ampulla of Vater. Subsequently, sludge in the common bile duct was cleaned, and balloon dilatation was performed. The general condition improved daily. The patient was discharged in a stable condition and followed in our outpatient department. CONCLUSION: This case involved an ampulla of Vater in an unusual location. Endoscopic retrograde cholangiopancreatography with balloon dilatation is the main treatment recommended and performed.

A rare case of transient portal venous gas.

Hepatic portal venous gas, while a rare finding with a classically poor prognosis, is not always fatal. Mortality varies depending on the underlying etiology; bowel ischemia carries the highest mortality rate. Other etiologies include gastrointestinal obstruction, gastric ulcer, infectious processes (intraperitoneal abscess and gastroenteritis), inflammatory processes (ulcerative colitis, Crohn disease, chemotherapy-induced), and complications from endoscopic procedures. We report a case of a 68-year-old woman who presented with a week-long history of diminished intake, nausea, and vomiting, with unremarkable abdominal examination, who was found to have significant portal venous gas that completely resolved within 16 hours without surgical intervention.

A Rare Presentation of Choledochoduodenal Fistula Due to Ovarian Cancer Metastasis.

Choledochoduodenal fistula (CDF) is an abnormal communication between the common bile duct and the duodenum. It accounts for about 5% to 25% of the total biliary fistulas and is usually due to a perforated duodenal ulcer, choledocholithiasis, and complications secondary to tuberculosis or could be iatrogenic. Primary intrabilliary tumors usually cause obstructive jaundice and rarely biliary metastasis arising from other organs like colon, breast, and lungs can cause obstructive jaundice. There has been a case report of metastasis from ovarian cancer to the major papilla of the duodenum but no reported cases of it causing a CDF. We report a rare case of an 83-year-old female with ovarian cancer who developed a metastatic lesion to the duodenum eventually resulting in a CDF.

Is It Really SUMP Syndrome? A Case Report.

Sump syndrome is a rare, long-term complication with a prevalence ranging from 0% to 9.6% in patients with a history of side-to-side choledochoduodenostomy. Choledochoduodenostomy was originally performed to achieve drainage of the common bile duct in high-risk patients with low morbidity, which was commonly done in the pre-endoscopic retrograde cholangiopancreatography era. "Sump" comes from the segment of the common bile duct between the anastomosis and the ampulla of Vater, which acts as a stagnant reservoir for debris, stones, and static bile. This predisposes patients to changes in the biliary tree with signs and symptoms in relation to that area. If left untreated, cholangitis, pancreatitis, hepatic abscesses, and secondary biliary cirrhosis can develop. Here, we have a case of a 77-year-old male with a history significant for choledochoduodenostomy, who presented with the clinical signs and symptoms of pancreatitis, choledocholithiasis, and urinary tract infection. Computed tomography (CT) scan findings revealed choledocholithiasis and an enlarged common bile duct with smaller adjacent calculi along with pneumobilia consistent with sump syndrome. The patient's clinical status improved without invasive measures being taken, i.e. endoscopic retrograde cholangiopancreatography. He was subsequently discharged home after improving clinically and no invasive measures were pursued.

Bouveret's Syndrome.

Bouveret syndrome is a very rare form of gastric outlet obstruction following the passage of a gallstone from the gallbladder to the duodenum or pylorus through a bilioenteric fistula. We present a unique case of a 78-year-old male complaining of right upper quadrant abdominal pain and who was found to have a gallstone in the proximal duodenum along with pneumobilia and cholecysto-duodenal fistula suggestive of Bouveret's syndrome.

Rare cause of gastric outlet obstruction.

Bouveret's syndrome is a rare cause of gastric outlet obstruction. The stones enter the small bowel via cholecysto-enteric fistula. The most common presenting symptoms are abdominal pain, nausea and vomiting. The gold standard diagnostic test isesophagogastroduodenoscopy (EGD). Rigler's triad on abdominal x-ray is classic. CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum. We present a case of a 75-year-old female who presents with 3 week history of nausea, vomiting, and diffuse abdominal pain. Initial presentation, imaging and EGD was concerning for malignancy. She was later diagnosed to have Bouveret's syndrome and underwent laparoscopic small bowel enterotomy with removal of gallstones.