A 44-year-old man was referred to our hospital with a 2-week history of abdominal distention, nausea and recurrent vomiting. The past medical history disclosed peptic ulcer-related duodenal stenosis at the bulb for 3 years and cholecystolithiasis for 20 years. On examination, the abdomen was distended and soft with no tenderness. Blood laboratory tests showed leucocytosis (12.10×109/L, reference 3.5–9.5), mild hypokalaemia (3.25 mmol/L, reference 3.5–5.3), normal C reactive protein, liver function, renal function and coagulation function. An abdominal CT showed a typical Rigler’s triad: pneumobilia, …