Bouveret’s syndrome complicated by a distal gallstone Ileus

Figure 1 Endoscopic appearance of a large duodenal stone (black arrows) causing complete obstruction. Note the irregu-lar edges of the stone (white arrows), which indicate its fragmentation.

Figure 2 CT shows: A: A large, 5×3×3 cm, intraluminal stone (arrow) in the proximal jejunum, B: Another stone in the duode-nal bulb (arrow).

Figure 3 Intraoperative views: A: The obstructed proximal jejunal segment, note a large intraluminal stone causing complete intestinal obstruction at this level, B: Removal of the stone with enterotomy, C: Macroscopic view of the fragmented gallstone which had a very hard outer shell with a soft core.

Figure 4 After the adhesions between the gallbladder (arrow) and the adjacent organs were dissected, cholecystoduodenal fistula (arrow head) was broken down and then the retained stone was removed.

Figure 5 Intraoperative ultrasound revealed that the suspicious stone was in the gallbladder instead of the duodenal lumen.