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 rst 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;23:272274 )

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 rst case of a migrating calcied gallstone lodged in mediastinum. In addition, we review a possible dierential diagnosis of such unusual chest radiography and computed tomography (CT) observed in this patient after yatrogenic esophageal perforation.

causing gastric outlet obstruction (Fig. 1). With the diagnosis of Bouveret syndrome, the patient underwent esophagogastroscopy that revealed mild distal esophagitis and conrmed the radiologic ndings. 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 stulous 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 conrmed 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 calcied 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-uid levels and a lling 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 calcied 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 lm showed a stone in right upper abdominal quadrant. Subsequently, a gastroduodenal examination with gastrogran conrmed 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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Migrating Intrathoracic Gallstone

FIGURE 4. The dilated stomach and proximal duodenum demonstrates air-fluid levels and a filling defect of increased density in the duodenum, measuring 2.5 cm. FIGURE 2. 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, which suggest pneumomediastinum and subcutaneous emphysema secondary to esophagus perforation. CT indicates computed tomography. main bronchus, conrming the diagnosis. The patient did well postoperatively and had no biliary problems at 1-year follow-up.

DISCUSSION
Gallstone migration is possible when a cholecystoenteric stula is present. The main cause of stula is cholecystitis, and less often, peptic ulcer, tumor or

spontaneous.2 The most common pathway of the gallstone starts more frequently by a cholecystoduodenal stula followed by cholecystocolic and choledocoduodenal stulas. Finally, the migration of the gallstone may nish by lodging in the ileum, jejunum, colon, duodenum, or stomach. 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%.4 A few cases of esophagus rupture have been described owing to the intralumen rise of pressure produced by the vomiting.5

FIGURE 3. A and B, Thoracoabdominal computed tomography with oral and intravenous contrast material shows an extraluminal laminated stone with a diameter of 2.5 cm lodged under the left main bronchus. Pneumomediastinum and subcutaneous emphysema in the chest wall are also noted.
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FIGURE 5. Coronal MIP reconstruction showing calcified stones in mediastinum and duodenum. MIP indicates maximum intensity algorithm.

Classic radiologic ndings (classically known as Rigler triad), including pneumobilia, small bowel obstruction, and ectopic gallstone, are present in 40% to 50% of patients.6 Gastroduodenal examination with barium or gastrogran is sometimes useful as it can demonstrate the stulous tract and the lling defect in the duodenum. CT is probably the gold-standard technique in the diagnosis of Bouveret syndrome.7 Oral contrast administration increases the sensitivity as it can reveal the stulous tract and show gallstones surrounded by contrast material. Several case reports of patients with Bouveret syndrome have been published focused on abdominal ndings.4,68 On the other hand, our case showed outstanding thoracic CT ndings caused by esophageal laceration after endoscopic retrievement attempt with gallstone migration to the paraesophageal space. Chest radiography showed 1 calcied stone lodged under the left main bronchus quite similar as a calcied lymphadenopathy. A lot of causes can be included in the dierential diagnosis of mediastinal calcications including calcied mediastinal lymph nodes depicted with dierent distribution and patterns in silicosis, sarcoidosis or tuberculosis, amyloidosis or progressive scleroderma, mediastinal Castleman disease, and metastatic tumors like bronchogenic and ovarian carcinoma. Primary tumors include

Hodgkin disease, especially after chemotherapy and radiotherapy and less often germ-cell tumors. Between other rare causes of mediastinal calcication described are calcied hematomas, calcied superior vena cava thrombosis, or esophageal duplication cyst and leiomyoma observed as a calcied mass in posterior mediastinum. 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.1 However, our case is the rst imaging report of a gallstone migrated into the mediastinum. Treatment of Bouveret syndrome is controversial. If physical condition and age of the patient allow surgery, enterolithotomy can be performed, and cholecystectomy or repairing of the stula may not be necessary.9 An alternative to surgery is endoscopy, being endoscopic lithotomy a rst option. As in our case, if gallstones are too large, mechanical fragmentation or lithotripsy by laser or extracorporeal shock-wave lithotripsy can be performed. It is important to consider factors such as gallstones size or presence of esophagitis to avoid complications like esophagus tear observed in our case. In summary, a migrating gallstone can be lodged in paraesophageal space after complicated endoscopic attempt of Bouveret syndrome treatment. Chest radiography and CT ndings in these patients are very characteristic and permit an accurate diagnosis in a certain clinical setting. REFERENCES
1. Fontaine JP, Issa RA, Yantiss RK, et al. Intrathoracic gallstones: a case report and literature review. JSLS. 2006;10:375378. 2. Palomar M, Tubia JI, Elorza JL. Fistulas biliodigestivas espontaneas. Rev Esp Enf Digest. 1990;77:3338. 3. Mallvaux P, Degolla R, De-Saint-Hubert M, et al. Laparoscopic treatment of gastric outlet obstruction caused by gallstone (Bouverets syndrome). Surg Endosc. 2002;16:11081109. 4. Modi BP, Owens C, Ashley SW. Bouveret meets Boerhaave. Ann Thorac Surg. 2006;81:14931495. 5. Clavien PA, Richon J, Burgan S, et al. Gallstone ileus. Br J Surg. 1990;77:737742. 6. Brennan GB, Rosenberg RD, Arora S. Bouveret syndrome. Radiographics. 2004;24:11711175. 7. Farman J, Goldstein DJ, Sugalski MT, et al. Bouverets syndrome: diagnosis by helical CT scan. Clin Imaging. 1998;22:240242. 8. Langhorst J, Schumacher B, Deselaers T, et al. Successful endoscopic therapy of a gastric outlet obstruction due to gallstone with intracorporeal laser lithotripsy: a case of Bouverets syndrome. Gastrointest Endosc. 2000;51:209213. 9. Lobo DN, Jobling JC, Balfour TW. Gallstone ileus: Diagnostic pitfalls and therapeutic successes. J Clin Gastroenterol. 2000;30: 7276.

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