University of Connecticut Health Center Plantsville, CT, United States
Teresa Da Cunha, MD, Bashar Sharma, MD, Steven Goldenberg, MD University of Connecticut Health Center, Farmington, CT
Introduction: Gallstone ileus accounts for 25% of nonstrangulated bowel obstruction with a higher incidence in elderly women. Commonly, the site of stone impaction is the terminal ileum. Nonetheless, a small percentage (4%) travel to the colon via a cholecystocolonic fistula causing bowel obstruction and are associated with a high mortality rate. We describe a case of colonic gallstone ileus in whom endoscopic treatment was not successful.
Case Description/Methods: An 89-year-old male with history of stroke, atrial fibrillation, heart failure, esophageal adenocarcinoma status post radiation, cholecystitis one year before (treated with percutaneous cholecystostomy tube), presented to the emergency room with left lower quadrant abdominal pain of two-day duration. He denied nausea, vomiting or fever. Initial vital signs, CBC, BMP and LFTs were unremarkable. CT abdomen showed cholelithiasis, fistulization of the gallbladder with the hepatic flexure and a large lamellated stone (3 x 2.6 cm) in the distal descending colon (Fig.1A). Treatment with aggressive bowel regimen was unsuccessful. Gastrografin enema revealed sigmoidal diverticular structuring disease (Fig.1B). Due to his age and comorbidities, he was not a surgical candidate and an endoscopic approach to remove the stone was attempted. Colonoscopy showed a large black stone completely obstructing the sigmoid colon (Fig. 1C). Attempts to pass as guidewire proximal to the stone to pursue balloon assisted dislodgment of the stone or mechanical lithotripsy as well as attempts to capture the stone in a retrieval net were unsuccessful. Exploratory laparotomy with partial left colectomy was performed. Pathology showed a 3.4 x 2.7 cm black stone and a 4.5 x 3 cm transmural defect at the colonic wall. Unfortunately, the patient’s overall nutrition deteriorated, and he expired 15 days after.
Discussion: Laparotomy is the standard approach in the management of colonic gallstone ileus. Endoscopic treatment has been reported in the literature with only a few successful cases mainly using mechanical or electrohydraulic lithotripsy. Several factors influence this outcome including stone size, the presence of colonic stricture, time to treatment and lack of expertise or availability. In our patient, the failure of the endoscopic approach was likely a combination of these factors. Management of colonic gallstone ileus in high risk patients is challenging, an endoscopic approach using the available tools and expertise should be attempted in the presence of surgical support.
Figure: Fig. 1 A: CT abdomen pelvis shows large lamellated stone in the distal descending colon (red arrow points to the stone); B: Gastrograffin enema showing diverticular structuring and a 32 mm calculus in the descending colon; C and D: Large pigmented gallstone seen at the sigmoid level during colonoscopy.
Disclosures: Teresa Da Cunha indicated no relevant financial relationships. Bashar Sharma indicated no relevant financial relationships. Steven Goldenberg indicated no relevant financial relationships.
Teresa Da Cunha, MD, Bashar Sharma, MD, Steven Goldenberg, MD. P2533 - Colonic Gallstone Ileus: An Endoscopic Challenge, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.