What two conditions are shown here ?

What is the most likely pathology ?

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(See below for further details)

 

 

 

Internal fistulae from the gall bladder may enter the duodenum, colon or common bile duct (Mirrizi Syndrome). Fistulation to the skin either directly or via the pleural cavity has been reported. Gall stone ileus results from fistulation to the duodenum with passage of a large stone into the bowel which become impacted in the distal ileum. The classical presentation is of a small bowel obstruction with gas in the biliary tree. Usually it is best to remove the impacted stone but to leave the gall bladder in situ as its removal will lead to a large, inflammatory defect in the duodenal wall which will prove very difficult to close. Cholecyst-colonic fistula is much less common but presents with weight loss and diarrhoea. Mirrizi syndrome with fistulation into the CBD may present as jaundice but might also be found during routine cholecystectomy. It is classically treated by cholecystectomy with division of the CBD and formation of a Roux-en-Y hepatico-jejunostomy although more conservative approaches have been described. Simple cholecystectomy and insertion of a t tube into the CBD or simple repair of the CBD will often lead to a late stricture of the CBD and jaundice.