P0108 - Endoscopic Management of a Unique Presentation of Gallstone Ileus

Adam S. Myer, MD¹, Connie Park, MD², Lionel S. D'Souza, MD^3
1Stony Brook University Hospital, Port Jefferson, NY; ²SUNY Stony Brook, Ronkonkoma, NY; ³Stony Brook University Hospital, Stony Brook, NY

Introduction: Gallstone ileus is a rare mechanical cause of intestinal obstruction. A large gallstone that passes into the GI tract can cause intestinal obstruction which most commonly occurs in the terminal ileum or at the ileocecal valve. The treatment is usually laparoscopic enterolithotomy. We present a unique case of gallstone ileus allowing for endoscopic management with the aid of mechanical lithotripsy.

Case Description/Methods: A 25-year-old man with a history of Hirschsprung disease and an ileostomy presented to the hospital with an acute onset of nausea and vomiting. This was associated with abdominal discomfort and mild abdominal distension. He reported no output through the ostomy for 24 hours. On presentation, he was afebrile and hemodynamically stable with the physical exam revealing mild abdominal distension and erythema at the ostomy. Blood work revealed a WBC count of 11.5 k/µL and normal serum lactate. Computed tomography of the abdomen and pelvis revealed a high-density structure at the ostomy site with fecalization and dilation of the ileum and jejunum proximally, consistent with small bowel obstruction. The patient underwent ileoscopy, which revealed a large 2.5 cm gallstone just proximal to the stoma. Attempts to retrieve the stone with a Roth net were unsuccessful as the stone was too large to pass through the stoma. Attempts remained unsuccessful even after balloon dilation of the stoma. A mechanical lithotripter was then used through a therapeutic gastroscope to break up the stone followed by retrieval of the stone fragments. The patient did well post procedure with a significant improvement in ostomy output and was subsequently discharged.

Discussion: Gallstone ileus is a rare complication of cholelithiasis and cholecystitis and usually occurs in the setting of a cholecystoenteric fistula, most commonly between the gallbladder and duodenum. In our patient, there was no imaging evidence of a cholecystoenteric fistula or pneumobilia; raising the possibility of a prior, healed, fistula. The treatment is usually surgical however, endoscopic access through the ileostomy allowed for disimpaction of the stone and mechanical lithotripsy for stone fragmentation and subsequent retrieval. Endoscopy, with mechanical, electrohydraulic or laser lithotripsy, can be an effective option in certain cases of gallstone ileus.


Figure: Panel A: CT abdomen pelvis with IV contrast showing (red circle) a high-density material with internal gas locules at the right anterior abdominal wall ileostomy ostium.
Panel B: Endoscopic view showing an approximately 2 cm gallstone. A mechanical lithotripter was used to break up the stone.


Disclosures:
Adam Myer indicated no relevant financial relationships.
Connie Park indicated no relevant financial relationships.
Lionel D''Souza indicated no relevant financial relationships.


Adam S. Myer, MD¹, Connie Park, MD², Lionel S. D'Souza, MD³. P0108 - Endoscopic Management of a Unique Presentation of Gallstone Ileus, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.