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CASE REPORT

Migrating Intrathoracic Gallstone
Imaging Findings
Laura Martin-Cuesta, MD, Enrique Marco de Lucas, MD, Raul Pellon, MD, Elena Sanchez, MD, Tatiana Piedra, MD, Javier Arnaiz, MD, Jose Antonio Parra, MD, and Manuel Lopez-Calderon, MD

Abstract: We present the case of a 76-year-old man referred to our hospital with a round stone in central mediastinum and pneumomediastinum in chest radiography and computed tomography. He had a previous history of attempt of endoscopic retrievement of a gallstone that had caused a gastric outlet obstruction (Bouveret syndrome). To our knowledge, this is the first imaging description of mediastinal gallstone caused by esophagus perforation during complicated endoscopic lithotomy. Key Words: ectopic mediastinic gallstone, Bouveret syndrome, yatrogenic esophageal perforation (J Thorac Imaging 2008;23:272–274 )

igration of a gallstone to the thoracic cavity has been described exceptionally as a very rare complication described after laparoscopic cholecystectomy.1 On the other hand, endoscopic retrievement is considered a standard treatment option in gastric outlet obstruction caused by a gallstone (Bouveret syndrome). However, it may be complicated because of esophagitis associated to repetitive vomiting in these patients. To our knowledge, we present the first case of a migrating calcified gallstone lodged in mediastinum. In addition, we review a possible differential diagnosis of such unusual chest radiography and computed tomography (CT) observed in this patient after yatrogenic esophageal perforation.

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causing gastric outlet obstruction (Fig. 1). With the diagnosis of Bouveret syndrome, the patient underwent esophagogastroscopy that revealed mild distal esophagitis and confirmed the radiologic findings. In the attempt to retrieve the stone through the esophagus, it became impacted in the midesophagus. A foreign bodies forceps was used to break the gallstone and push the fragments into the stomach. The examination of the mucosa showed a fistulous hole in the midesophagus and, clinically, the patient developed cervical subcutaneous emphysema. The patient was referred to the emergency department of our hospital. Chest radiography demonstrated a round stone in central mediastinum and streaky lucencies that extend into the soft tissues of the neck and chest, which suggest pneumomediastinum and subcutaneous emphysema secondary to esophagus perforation (Fig. 2). Thoracoabdominal helical CT with oral and intravenous contrast material confirmed the presence of pneumomediastinum and subcutaneous emphysema in the neck and chest wall. The esophagus was distended and showed a loss of continuity of the esophageal left wall with an extraluminal ectopic calcified stone with a maximal diameter of 2.5 cm lodged under the left main bronchus (Fig. 3). The dilated stomach and proximal duodenum showed air-fluid levels and a filling defect of increased density in the duodenum, measuring 2.5 cm (Figs. 4, 5). With the diagnosis of esophagus perforation secondary to endoscopic lithotomy in a patient with Bouveret syndrome, he underwent surgery for repairing the esophagus tear and placement of endotracheal and nasogastric drainages. During the procedure, a calcified gallstone was visualized next to the left

CASE REPORT
A 76-year-old man diagnosed of chronic bronchitis presented to the emergency department with a 4-day history of mild distended abdomen with pain in right upper quadrant. Abdominal plain film showed a stone in right upper abdominal quadrant. Subsequently, a gastroduodenal examination with gastrografin confirmed a 4-cm ectopic gallstone in the pylorus
From the Department of Radiology, Marques de Valdecilla University Hospital, Santander, Spain. Reprints: Laura Martin Cuesta, MD, Department of Radiology, Marques de Valdecilla University Hospital, Av. Valdecilla s/n. 39008, Santander, Spain (e-mail: lamacue@yahoo.com). Copyright r 2008 by Lippincott Williams & Wilkins

FIGURE 1. Gastroduodenal examination with gastrografin shows a 4-cm ectopic gallstone in the pylorus causing gastric outlet obstruction. J Thorac Imaging 

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Volume 23, Number 4, November 2008

CT indicates computed tomography. The main cause of fistula is cholecystitis. or stomach. A and B.4 A few cases of esophagus rupture have been described owing to the intralumen rise of pressure produced by the vomiting.5 cm lodged under the left main bronchus. November 2008 Migrating Intrathoracic Gallstone FIGURE 4. Finally. Thoracoabdominal computed tomography with oral and intravenous contrast material shows an extraluminal laminated stone with a diameter of 2. main bronchus.5 FIGURE 3. The dilated stomach and proximal duodenum demonstrates air-fluid levels and a filling defect of increased density in the duodenum. Number 4. and less often. Pneumomediastinum and subcutaneous emphysema in the chest wall are also noted.5 cm. which suggest pneumomediastinum and subcutaneous emphysema secondary to esophagus perforation. The patient did well postoperatively and had no biliary problems at 1-year follow-up. Scout image from helical CT scan demonstrates a round stone in middle mediastinum and streaky lucencies that extend into the soft tissues of the neck and chest. measuring 2. peptic ulcer. colon. r 2008 Lippincott Williams & Wilkins 273 . duodenum. DISCUSSION Gallstone migration is possible when a cholecystoenteric fistula is present. confirming the diagnosis. the migration of the gallstone may finish by lodging in the ileum. FIGURE 2. Bouveret syndrome is an unusual type of gallstone ileus consisting on an obstruction at the level of the distal stomach or proximal duodenum and represents <5% of gallstone ileus.3 This syndrome predominates in elderly women and its prompt diagnosis is important because mortality rate has been reported to be as high as 30%. tumor or spontaneous.2 The most common pathway of the gallstone starts more frequently by a cholecystoduodenal fistula followed by cholecystocolic and choledocoduodenal fistulas. jejunum.J Thorac Imaging  Volume 23.

9 An alternative to surgery is endoscopy. 9.6 Gastroduodenal examination with barium or gastrografin is sometimes useful as it can demonstrate the fistulous tract and the filling defect in the duodenum. Sugalski MT.Martin-Cuesta et al J Thorac Imaging  Volume 23. Laparoscopic treatment of gastric outlet obstruction caused by gallstone (Bouveret’s syndrome). 2004. et al. Langhorst J. Surg Endosc. 5. are present in 40% to 50% of patients. Deselaers T. Several case reports of patients with Bouveret syndrome have been published focused on abdominal findings. 7. including pneumobilia. mediastinal Castleman disease. In summary. Number 4. Fistulas biliodigestivas espontaneas. our case is the first imaging report of a gallstone migrated into the mediastinum. small bowel obstruction. 8. 2006. and ectopic gallstone. JSLS. 1990. mechanical fragmentation or lithotripsy by laser or extracorporeal shock-wave lithotripsy can be performed. Brennan GB. Arora S.7 Oral contrast administration increases the sensitivity as it can reveal the fistulous tract and show gallstones surrounded by contrast material. Goldstein DJ. As in our case. Burgan S. if gallstones are too large. De-Saint-Hubert M.51:209–213. Bouveret meets Boerhaave. Palomar M. Chest radiography and CT findings in these patients are very characteristic and permit an accurate diagnosis in a certain clinical setting. our case showed outstanding thoracic CT findings caused by esophageal laceration after endoscopic retrievement attempt with gallstone migration to the paraesophageal space. If physical condition and age of the patient allow surgery. 274 r 2008 Lippincott Williams & Wilkins . Coronal MIP reconstruction showing calcified stones in mediastinum and duodenum. 2002. et al. especially after chemotherapy and radiotherapy and less often germ-cell tumors. being endoscopic lithotomy a first option. Ann Thorac Surg. 1998. Bouveret’s syndrome: diagnosis by helical CT scan.81:1493–1495. Clavien PA. et al.30: 72–76. Primary tumors include Hodgkin disease. Lobo DN. J Clin Gastroenterol. Between other rare causes of mediastinal calcification described are calcified hematomas. Jobling JC. Ashley SW. or esophageal duplication cyst and leiomyoma observed as a calcified mass in posterior mediastinum. 3. CT is probably the gold-standard technique in the diagnosis of Bouveret syndrome. Gastrointest Endosc.6–8 On the other hand. Successful endoscopic therapy of a gastric outlet obstruction due to gallstone with intracorporeal laser lithotripsy: a case of Bouveret’s syndrome. Tubia JI. 2. amyloidosis or progressive scleroderma. Radiographics. Elorza JL. Fontaine JP. Yantiss RK. Br J Surg. and metastatic tumors like bronchogenic and ovarian carcinoma. 2000.1 However. Intrathoracic gallstones: a case report and literature review. Owens C. Bouveret syndrome. Farman J. Rev Esp Enf Digest. November 2008 FIGURE 5.22:240–242.4. a migrating gallstone can be lodged in paraesophageal space after complicated endoscopic attempt of Bouveret syndrome treatment. Gallstone ileus: Diagnostic pitfalls and therapeutic successes. 1990.77:737–742. Modi BP. Rosenberg RD. 2006. Balfour TW. Migration of a gallstone to the thoracic cavity has been described exceptionally as a very rare complication after laparoscopic cholecystectomy caused by migration through a diaphragm tear. et al. MIP indicates maximum intensity algorithm. and cholecystectomy or repairing of the fistula may not be necessary. 6. Classic radiologic findings (classically known as Rigler triad).10:375–378. REFERENCES 1. enterolithotomy can be performed. Chest radiography showed 1 calcified stone lodged under the left main bronchus quite similar as a calcified lymphadenopathy. Mallvaux P. Treatment of Bouveret syndrome is controversial. A lot of causes can be included in the differential diagnosis of mediastinal calcifications including calcified mediastinal lymph nodes depicted with different distribution and patterns in silicosis. Richon J. 4. Clin Imaging. 2000.24:1171–1175. Degolla R. sarcoidosis or tuberculosis.77:33–38. et al. It is important to consider factors such as gallstones size or presence of esophagitis to avoid complications like esophagus tear observed in our case.16:1108–1109. Issa RA. calcified superior vena cava thrombosis. Schumacher B. Gallstone ileus.