Gallstone Ileus following Endoscopic Stone Extraction

Abstract

An 85-year-old woman was an outpatient treated at Tokyo Rosai Hospital for cirrhosis caused by hepatitis B. She had previously been diagnosed as having common bile duct stones, for which she underwent endoscopic retrograde cholangiopancreatography (ERCP). However, as stone removal was unsuccessful, a plastic stent was placed after endoscopic sphincterotomy. In October 2012, the stent was replaced endoscopically because she developed cholangitis due to stent occlusion. Seven days later, we performed ERCP to treat recurring cholangitis. During the procedure, the stone was successfully removed by a balloon catheter when cleaning the common bile duct. The next day, the patient developed abdominal pain, abdominal distension, and nausea and was diagnosed as having gallstone ileus based on abdominal computed tomography (CT) and abdominal ultrasonography findings of an incarcerated stone in the terminal ileum. Although colonoscopy was performed after inserting an ileus tube, no stone was visible. Subsequent CT imaging verified the disappearance of the incarcerated stone from the ileum, suggesting that the stone had been evacuated naturally via the transanal route. Although it is extremely rare for gallstone ileus to develop as a complication of ERCP, physicians should be aware of gallstone ileus and follow patients carefully, especially after removing huge stones.

Figure 1

Abdominal computed tomographic (CT) image showing the common bile duct stone (arrow) accompanied by fat stranding in the surrounding adipose tissue on hospital day 47.

Figure 2

Endoscopic retrograde cholangiopancreatography (ERCP) images on hospital day 57. (a) Long-standing huge stone in the common bile duct (arrows). (b) A large amount of biliary sludge (arrowheads) and the stone, which had been difficult to remove, were washed out by a balloon catheter inserted to drain biliary sludge and infected bile (unable to photograph the stone). (c) Enhanced CT image showing no stone or biliary sludge remaining in the common bile duct after cleaning.

Figure 3

Abdominal CT image showing the stone (arrow) in the ileocecal region on hospital day 59. The stone was successfully passed into the duodenum in the previous ERCP. The image also shows distension of the small intestine proximal to the stone and the accumulation of intraluminal fluid (arrowheads), the latter of which had increased since CT imaging on hospital day 47.

Figure 4

Abdominal ultrasound image on hospital day 59 showing a hyperechoic solid space-occupying lesion (45 × 23 mm) with acoustic shadowing (arrows) in the ileocecal region.

Figure 5

Colonoscopy on hospital day 66 showing (a) the ileocecal region and (b) ileum. No stone was observed during observation of the small intestine up to 7 cm proximal to the terminal ileum.

Figure 6

Abdominal CT scan performed immediately after colonoscopy showing the absence of a stone and improved intestinal distension.