Small Bowel Obstruction Secondary to Large Gallstone
Introduction: Gallstone ileus is uncommon complication of chronic calculous cholecystitis that presents commonly with distal mechanical small bowel obstruction in elderly patients. It results from eroding the gallstone to the second part of the duodenum, creating a cholecystoduodenal fistula. The stone, usually those >2.5cm, will not pass through the gastrointestinal tract and results in mechanical obstruction, commonly in the terminal ileum. Management is focused initially on fluid resuscitation to restoring the patient’s intravascular volume. Because of the nature of this process, surgical intervention is almost always indicated to remove the stone from the small bowel with or without addressing the cholecystoenteric fistula at the initial operation. Case Report: A 65-year-old female with prior medical history of Hepatitis C and opioid addiction presented with a 1-week history of intermittent lower abdominal pain, nausea, and vomiting that became more frequent and colicky in nature within 24 hours of reporting to the Emergency Department. A computed tomography (CT) scan of the abdomen and pelvis identified abnormally dilated loops of proximal small bowel with a transition to normal caliber secondary to a hyperdense structure and a similar structure in the gallbladder with minimal adjacent presumed free air, suggesting a gallstone ileus with a cholecystoenteric fistula. The patient underwent an exploratory laparotomy, removal of a large fragment of gallstones (2.7x2.8 cm) from the small bowel through a small enterotomy. Due to the higher incidence of recurrent small bowel obstruction within 30-days, in the presence of the other half of the gallstone in the gallbladder, the decision was to proceed with subtotal cholecystectomy, removal of the stone fragment and closure of cholecystoduodenal fistula and Jejunostomy feeding tube placement. One week after surgery, an upper GI study showed no evidence of leak at fistula site. Diet was advanced as tolerated and the patient was discharged home on post-op day 11. Conclusion: Gallstone ileus is an uncommon condition that can present with mechanical small bowel obstruction. After resuscitation, surgical intervention is almost always required to remove the obstructing stone from the bowel. Cholecystectomy and closure of fistula are not necessary at the first operation if no residual stones in the gallbladder. This patient required multiple procedures due to her unusual presentation. Therefore, evaluation for gallstone ileus is crucial to determine the management strategy.