GS29 - Sigmoid Gallstone Ileus - A Case Report

Introduction/Purpose: Gallstone ileus is a rare and unusual complication of cholelithiasis that leads to mechanical ileus secondary to impaction of gallstone within the intestinal tract. In previous studies, the incidence of gallstone ileus was found in 0.15%–1.5% of cholelithiasis cases and < 0.1% of ileus cases overall. Notably, with a recurrence rate of 5%–8%. An extensive review from 2004 to 2009, showed an overall incident rate of 0.095%, making the incidence almost negligible. This disease process has a propensity to disproportionately affect the elderly women, who comprise roughly 70% of cases. Additionally, most gallstone ileus cases are managed with enterolithotomy (62%) with 19% of cases including cholecystectomy and concomitant fistula closure. Those patients undergoing enterolithotomy had significantly less morbidity and mortality than those undergoing cholecystectomy with fistula closure. This study draws many similarities with our case (including patient demographics, underlying comorbidities, and management) and further supports the claim that performing a simpler/less complex operation leads to improved patient outcomes.

Methods or Case Description: 69-year-old-woman presented to our institution with a chief complaint of abdominal pain with accompanying nausea, vomiting and constipation for approximately 1 week. Patient was noted to have multiple comorbidities, including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and recent Middle Cerebral Artery stroke. Vitals were significant for a body temperature of 36.7 degrees Celsius, blood pressure of 91/56 mmg Hg, and pulse rate of 114 beats/min. On physical exam, the patient displayed abdominal distention, tympany to percussion, tenderness to palpation in the left lower quadrant of her abdomen without peritonitis. Laboratory studies significant for leukocytosis with a white blood cell count of 16,200 u/L and electrolyte abnormalities (Potassium 3.0 mEq/L, Chloride 102 mEq/L). Computed tomography revealed multiple distended loops of bowel, pneumobilia and a 3.6 x 2.1 cm, high-density structure within the lumen of the distal sigmoid colon (Figures 1 and 2).

Based on these clinical findings, the patient was diagnosed with sigmoid gallstone ileus. Considering the risk of perforation and patient’s hemodynamics, an emergent laparotomy was performed. Laparotomy revealed distended loops of bowel proximal to the sigmoid colon. The stone was palpable within the rectosigmoid junction. A colotomy was performed, the stone was extracted and the colotomy closed in two layers with absorbable suture. Due to patient’s hemodynamic instability, we elected against a single staged procedure and did not address the cholecystocolonic fistula.

Following laparotomy, the patient was able to have return of bowel function by postoperative day (POD) 2 and was discharged on POD 4. Final pathology was consistent with a gallstone that measured 4.5 x 2.6 x 2.2 cm in dimension and weight of 23 grams.

Outcomes: As this case demonstrates, a two staged surgical approach to gallstone ileus is well-tolerated by elderly patients. It also provides good postoperative outcomes with minimal short-term complications despite a remnant cholecystocolonic fistula in situ. Although the one stage approach definitively addresses the underlying pathology, it also prolongs operative time and puts an intraoperatively unstable patient at risk of further decompensation.

In a patient demographic that is already highly vulnerable to the physiologic demands of surgery, this could be catastrophic. While laparotomy is currently the standard, it may be worth considering an initial laparoscopic technique if the patient is hemodynamically stable. Other possible methods to consider include endoscopic removal of the stone or lithotripsy. These alternatives may provide less invasive options in the future treatment of gallstone ileus.

Conclusion:

We present a rare case of gallstone ileus through cholecystocolonic fistula causing large bowel obstruction at the rectosigmoid junction. As described in the literature, gallstone ileus is more common in elderly females with multiple comorbidities. This patient underwent a simple enterolithotomy and was able to be discharged soon after her surgery without any complications. Owing to the high prevalence of gallstones, such cases may be presented in routine medical practice and clinicians should consider gallstone ileus in the differential diagnosis of an acute abdomen. However, selection of appropriate treatment is difficult due to the general poor health condition of the patients with ileus. Surgeons need to decide on the choice of immediate one-stage or two-stage closure of the cholecystointestinal fistula or simply allowing for natural closure. This case further supports the utilization of less complex surgical intervention to treat a rare and, perhaps, complex disease.