An 81-year-old man with multiple conditions presented with right hypochondrium pain, fever, nausea and persistent vomiting in the last 24 hours.
Physical examination revealed jaundice sclerosus and an abdomen with pain to the right hypochondrium without peritonitis.
Abdominal ultrasound and CT showed dilatation of the intrahepatic bile duct with aerobilia, gall bladder poorly delimited with lithiasis; large gallstone in the duodenal bulb that conditions obstruction and dilatation of the gastric chamber.
Upper endoscopy showed liquid content in the gastric cavity and in the duodenal bulb a large calculus occupying almost the entire lumen.
With the help of the lateral approach and litotriptor, a partial fragmentation of the calculus was performed, with removal of the calculi, leaving a fragment of approximately 2 cm in the duodenum. The patient shows significant clinical improvement with reduction of abdominal pain.
At 48 hours follow-up endoscopy showed an image suggestive of biliary-duodenal fistula and absence of the calculus described.
The patient was discharged on the fifth day in good clinical condition and with marked improvement of stasis parameters.
Given the high surgical risk an expectant attitude was decided, the patient is symptomatic at 12 months of follow-up.
