case_images: PMC6794980_01
case_images: ERCP shows multiple stones in the common bile duct (red arrow).
case_images: CRIGM2019-8907068.001.jpg
case_images: PMC6794980_01_CRIGM2019-8907068.001.jpg
case_images: fig1
case_images: A forty nine-year-old female presented to the emergency department due to episodes of sudden cramping, epigastric pain and nausea 2 months following endoscopic retrograde cholangiopancreatography (ERCP) where three gallstones were removed from the common bile ducts (Figure 1).
case_images: Abdominal ultrasound depicting a large stone in the gallbladder (red arrow).
case_images: CRIGM2019-8907068.002.jpg
case_images: PMC6794980_01_CRIGM2019-8907068.002.jpg
case_images: fig2
case_images: Before she underwent ERCP and endoscopic sphincterotomy, right upper quadrant abdominal ultrasound done on account of obstructive jaundice showed a noninflammed gallbladder with a large stone and a dilated common bile duct (Figure 2).
case_images: Contrast CT scan depicting gallstone in bowel (short red arrow).
case_images: CRIGM2019-8907068.003.jpg
case_images: PMC6794980_01_CRIGM2019-8907068.003.jpg
case_images: fig3
case_images: At presentation, her abdominal computed tomography (CT) revealed evidence of small bowel obstruction with clear evidence of gallstone ileus (Figure 3). A large, calcified 3.5 cm x 3 cm gallstone was found in the small bowel impacted at 60 cm proximal to the ileocecal valve (Figure 3) with evidence of pressure necrosis to the bowel.
case_images: Contrast CT scan depicting cholecystoduodenal fistula (short red arrow).
case_images: CRIGM2019-8907068.004.jpg
case_images: PMC6794980_01_CRIGM2019-8907068.004.jpg
case_images: fig4
case_images: A cholecystoduodenal fistula was also present (Figure 4).
case_images: CT contrast scan depicting decompressed GB and air in GB, verifying that a stone was released (short red arrow).
case_images: CRIGM2019-8907068.005.jpg
case_images: PMC6794980_01_CRIGM2019-8907068.005.jpg
case_images: fig5
case_images: Evidence of a decompressed gallbladder (Figure 5) and a clear transition point were noted.
case_images: CT contrast scan depicting bowel anastomosis after 1st surgery (short red arrow).
case_images: CRIGM2019-8907068.006.jpg
case_images: PMC6794980_01_CRIGM2019-8907068.006.jpg
case_images: fig6
case_images: The segment that had the stone was identified and exteriorized through a small midline incision; the bowel was necrotic due to pressure ischemia; thus segmental bowel resection was performed with stapled anastomosis (Figure 6).
case_images: CT contrast scan depicting free air in pocket of abscess where bowel was perforated (short red arrow).
case_images: CRIGM2019-8907068.007.jpg
case_images: PMC6794980_01_CRIGM2019-8907068.007.jpg
case_images: fig7
case_images: PE, but positive for free air (Figure 7). Patient was taken back to the OR for laparotomy, which revealed a second large non-calcified gallstone in the ileum impacted at the ileocecal valve distal to the previous anastomosis and perforated necrotic small bowel with a pocket of abscess.