Jolian Kathawa, DO1, Revanda Karana, BS2, Marc Piper, MD, MSc1 1Providence Hospital, Southfield, MI; 2Wayne State University, Detroit, MI
Introduction: Gallstone ileus is a rare condition associated with high mortality that is generally caused by the passage of a stone through a cholecystoenteric fistula and subsequently causes an intestinal obstruction. It is very rare for patients to have gallstone ileus many years post-cholecystectomy. We present a case of gallstone ileus that is interesting for a couple reasons: (1) patient developed the ileus 6 years post-cholecystectomy and (2) there is no objective evidence of a cholecystoenteric fistula.
Case Description/Methods: 80-year-old woman with a history of cholecystitis (requiring cholecystectomy 6 years ago) presented with nausea, vomiting and decreased appetite for 6 days. Exam revealed tenderness on palpation in the right upper quadrant. Labs revealed mild leukocytosis. An x-ray revealed a lamellated density within the right lower quadrant measuring 4.8 x 2.0 cm and multiple dilated loops of small bowel in the visualized abdomen measuring up to 6.7 cm. A CT scan of the abd/pelvis with contrast revealed a lamellated density within the mid to distal ileum with distally collapsed loops of small bowel and proximately dilated loops of bowel measuring up to 5.7 cm. Gallbladder was absent and no pneumobilia was noted. The patient underwent exploratory laparotomy. Small bowel resection was performed with removal of the foreign body. The foreign body was a green, smooth ovoid calculus that was 6.5 x 3.0 x 2.5 cm in size and confirmed as a gallstone via microscopic examination. The patient did well post-operatively and was discharged on day 9.
Discussion: In patients presenting with small bowel obstruction, about 0.5% of these cases are due to a gallstone ileus. The entry of the gallstone into the small intestine is typically through a biliary enteric fistula which occurs in about 2-3% of all cases of cholecystitis. We postulate that the patient developed a cholecystoenteric fistula after her episode of cholecystitis 6 years ago. She may have passed the large gallstone immediately afterwards, but may have been lodged within a diverticulum until prior to the onset of her symptoms when it dislodged and caused an obstruction. Although our patient did not exhibit evidence of pneumobilia, it has been reported that it is present in only 30% of cases so this should not exclude the presence of a fistula. It is important to recognize that patients may develop gallstone ileus years after a cholecystectomy and to not delay diagnosis or treatment in patients who present with symptoms of gallstone ileus.
Figure: Figure A. X-ray demonstrating lamellated density in right lower quadrant, identified by red arrows. Figure B. Computed tomography scan demonstrating lamellated density in mid to distal ileum, identified by red arrow.
Disclosures: Jolian Kathawa indicated no relevant financial relationships. Revanda Karana indicated no relevant financial relationships. Marc Piper indicated no relevant financial relationships.
Jolian Kathawa, DO1, Revanda Karana, BS2, Marc Piper, MD, MSc1. P1109 - An Unusual Case of Gallstone Ileus 6 Years Post-Cholecystectomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.