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DOI:10.2214/AJR.07.3418
AJR 2008; 191:182-185
© American Roentgen Ray Society

Clinical Observations

More than Meets the Eye: Subtle but Important CT Findings in Bouveret's Syndrome

Susan Gan1, Shuvro Roy-Choudhury2, Sanjay Agrawal1, Harish Kumar1, Arvind Pallan2, Paul Super1 and Martin Richardson1

1 Department of Upper Gastrointestinal Surgery, Heartlands Education Center, Birmingham Heartlands Hospital, Birmingham, United Kingdom.
2 Department of Radiology, Birmingham Heartlands Hospital, 45 Bordesley Green East, Birmingham, United Kingdom B9 5SS.

OBJECTIVE. Gallstones are a rare cause of duodenal or gastric outlet obstruction and therefore are not commonly suspected. Rigler's radiographic triad of pneumobilia, bowel obstruction, and an ectopic gallstone is seen in few of these patients. The symptoms are insidious and nonspecific, and the diagnosis is usually made radiologically. Although CT scans are far more sensitive, 25% of cases are still missed, often because the size of the offending gallstone is underestimated.

CONCLUSION. Better assessment of stone size, and therefore higher accuracy of diagnosis, could be achieved if attention is paid to more subtle but nonetheless important signs. These include compressed air in dependent areas of the duodenal lumen, an area of soft-tissue rather than fluid density surrounding the calcified rim of the stone, and a faint radiolucency in or beyond this soft-tissue area that could represent laminations of fat or air in the stone.

Keywords: Bouveret's syndrome • CT • gastric outlet obstruction • gallstone ileus


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