A 64-year-old man presented with abdominal distension, pain, and vomiting for 5 days. Computed tomography scan of the abdomen showed dilated small intestine and colon, air in the biliary tree, and a calcified mass in the sigmoid colon. Colonoscopy showed a large impacted stone in the sigmoid colon. This was likely a migrated gall bladder stone, given history of cholecystitis. The stone was too large and smooth to be removed endoscopically. Fragmentation of the stone with electrohydraulic lithotripsy (EHL) could only partially fracture the stone. The cut surface showed a firm, crystalline structure. During EHL the stone got dislodged and moved distally into the rectum. The colonoscope could then be passed proximal to the site of impaction. Edematous mucosa and ulcerations were seen in the proximal sigmoid colon. The stone was then removed transanally in the operating room using sponge forceps. The stone measured 8 cm × 5 cm. The patient did well postoperatively and was discharged home the next day.
Gallstone ileus is a rare complication of cholelithiasis and occurs mostly in the elderly. It accounts for 1% to 3% of all mechanical intestinal obstructions. The preceding episodes of recurrent calculous cholecystitis usually result in extensive inflammation and adhesions between the gallbladder and the gastrointestinal tract. This facilitates the erosion by the gallstone through the wall of the gallbladder into the gut, resulting in a cholecystoenteric fistula with eventual passage of the gallstone into the gastrointestinal tract. Most of these stones are so small that they pass spontaneously without causing obstruction. The usual site of impaction is the terminal ileum, where the digestive tract is the narrowest. Colonic obstruction occurs in <5% of all cases. Surgery has been the mainstay for treating gallstone ileus, but it is associated with high morbidity and mortality. EHL and laser lithotripsy have proven to be highly effective in the endoscopic treatment of larger common bile duct stones, but their use in gallstone ileus ′has been limited to a few case reports. The gallstones in these cases were lodged in the stomach or the duodenum and were <4 cm in size. Only one case reported removal of a 4.1-cm-large stone from the sigmoid colon.
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-Sana Omair, MD, Omair Atiq, MD, Deepak Agrawal, MD
This article originally appeared in the June 2016 issue of The American Journal of Medicine.
