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Case Reports
. 2019 Oct 3:2019:8907068.
doi: 10.1155/2019/8907068. eCollection 2019.

Unusual Presentation of Recurrent Gallstone Ileus: A Case Report and Literature Review

Osayande Osagiede  1 , Paula Pacurari  2 , Dorin Colibaseanu  1 , Nezar Jrebi  3
Affiliations
Case Reports

Unusual Presentation of Recurrent Gallstone Ileus: A Case Report and Literature Review

Osayande Osagiede et al. Case Rep Gastrointest Med. .

Abstract

Background: Gallstone ileus (GSI) is a rare form of small bowel obstruction (SBO) in patients with cholelithiasis, which is often poorly managed. Enhanced abdominal computed tomography (CT) with contrast is considered the most helpful diagnostic tool, as it is highly sensitive, specific, and accurate. We report an interesting case of recurrent GSI that was not detected by CT but diagnosed intraoperatively.

Case presentation: A 49-year-old female with a previous history of choledocholithiasis and ERCP presented to the emergency department following episodes of sudden cramping, epigastric pain, and nausea. An abdominal CT revealed evidence of SBO with clear evidence of GSI and a cholecystoduodenal fistula. Laparoscopic exploration of the small bowel revealed a large, calcified 3.5 cm × 3 cm gallstone with evidence of pressure necrosis; segmental bowel resection with stapled anastomosis was performed and patient recovered appropriately after surgery. Cholecystectomy was not performed due to multiple co-morbidities and absence of gallbladder stones. However, she presented two months later with signs and symptoms of SBO. A repeat abdominal CT showed dilated bowel with no clear transition point. This was suspected to be due to adhesions. After an initial conservative treatment which produced mild improvement, laparotomy was performed which revealed a second large non-calcified gallstone and necrotic small bowel with a pocket of abscess.

Conclusion: The most sensitive diagnostic tool for GSI is enhanced abdominal CT but dilemma arises when GSI is not detected on CT. A high index of suspicion and further exploration are required in order not to miss other vital findings.

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Conflict of interest statement

The authors declare that they have no conflicts of interest.

Figures

Figure 1
Figure 1
ERCP shows multiple stones in the common bile duct (red arrow).
Figure 2
Figure 2
Abdominal ultrasound depicting a large stone in the gallbladder (red arrow).
Figure 3
Figure 3
Contrast CT scan depicting gallstone in bowel (short red arrow).
Figure 4
Figure 4
Contrast CT scan depicting cholecystoduodenal fistula (short red arrow).
Figure 5
Figure 5
CT contrast scan depicting decompressed GB and air in GB, verifying that a stone was released (short red arrow).
Figure 6
Figure 6
CT contrast scan depicting bowel anastomosis after 1st surgery (short red arrow).
Figure 7
Figure 7
CT contrast scan depicting free air in pocket of abscess where bowel was perforated (short red arrow).
See this image and copyright information in PMC

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