Gallstone Ileus: Strangulation of the Small Bowel Following a Remote History of a Cholecystectomy

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J Acute Care Surg. 2024;14(3):126-129

Publication date (electronic) : 2024 November 21

doi : https://doi.org/10.17479/jacs.2024.14.3.126

Sammy Shihadeh^a,, Kyle Carey^a, Luis Llerena^b, Ali Al-Rawi^b

^aFlorida State University College of Medicine, Tallahassee, FL, USA

^bDepartment of Emergency General Surgery, Trauma, Critical Care and Burns, Sarasota Memorial Health Care System, Sarasota, FL, USA

^*Corresponding Author: Sammy Shihadeh, Florida State University College of Medicine, 1115 West Call St, Tallahassee, FL 32306-4300, USA, Email: sas21x@med.fsu.edu

Received 2024 April 24; Revised 2024 September 18; Accepted 2024 September 19.

Abstract

Introduction

Gallstone ileus is a rare form of small bowel obstruction that may occur as a consequence of cholelithiasis and/or cholecystitis [1]. Classically, gallstone ileus is caused by inflammation of the gallbladder wall nearest to the duodenum, the formation of a choledochoduodenal fistula, and the subsequent passage of a gallbladder calculus into the bowel lumen [2]. This can result in pneumobilia (due to intestinal gas traveling through the fistula into the gallbladder), colicky abdominal pain, vomiting, and bloating [1,3]. In addition, small bowel obstruction, and its associated symptoms including abdominal distension, tenderness, and high-pitched borborygmi can also occur [3]. Gallstone ileus usually causes obstruction at the ileocecal valve, necessitating emergency enterolithotomy and cholecystectomy [4]. However, there have been rare cases reported in the literature of gallstone ileus occurring post-cholecystectomy [2,5–7]. Post-cholecystectomy gallstone ileus is an exceedingly rare presentation with only 6 cases reported in a review of 1,001 reported cases of gallstone ileus [8]. Here we present the case of a 93-year-old man, with a history of cholecystectomy (approximately 20 years ago), presenting with small bowel obstruction and peritoneal symptoms. He received an exploratory laparotomy and had small bowel resection and anastomosis of the proximal jejunum.

Case Report

The patient was a 93-year-old male who presented with acute onset abdominal pain, nausea, vomiting and tenderness around the umbilical area. The patient was not suffering with chest pain, shortness of breath, fever, or chills. His last bowel movement with noted hematochezia, was one day prior to his admission. Past medical history included malignant melanoma, a prior small bowel obstruction which was treated conservatively, adrenal gland cancer, chronic kidney disease, and family history of Barrett’s esophagus. Past surgical history included 2 prior coronary artery bypass grafts, cystectomy with ileal conduit, adrenal gland lesion resection, cholecystectomy [gallbladder fossa demonstrated by computed tomography (CT) in Figure 1], and resection of malignant mesothelioma. There was no apparent evidence of a cholecysto-duodenal fistula during the patient’s cholecystectomy (to the best of our knowledge and based on the patient’s history). The patient had a smoking history of 65 pack-years and denied alcohol use. The patient was not taking any medications that interfered with biliary secretion or digestion (and had reported normal bowel movements). Physical exam was pertinent for a soft abdomen with periumbilical tenderness to palpation and hypoactive bowel sounds were detected. Laboratory values at the time of admission were pertinent for low red blood cell count, low hematocrit, elevated segmented neutrophils, elevated absolute neutrophil count, hypomagnesemia, and a low glomerular filtration rate. The CT scan demonstrated proximal small bowel obstruction with dilation and distal decompression (Figure 2). Additionally, CT imaging also revealed the presence of a gallstone in the small bowel (Figure 3). The patient received a nasogastric (NG) tube for gastric decompression, nil per ostium, intravenous fluids, and conservative management for small bowel obstruction. The patient went on to develop peritonitis within 24 hours and required an emergent exploratory laparotomy.

Figure 1

Computed tomography scan of the gallbladder fossa consistent with history of cholecystectomy.

Figure 2

Computed tomography scan of dilated and decompressed small bowel distal to the gallstone.

Figure 3

Computed tomography scan of the gallstone present in the small bowel (red arrow).

Intraoperatively, significant lysis of adhesions was performed. These adhesions were observed in the right upper quadrant of the abdomen. The adhesions were most likely formed due to prior abdominal surgery but were not determined to be the cause of the gallstone ileus as there were no mechanical problems. Visual confirmation of a prior duodenal fistula that may have explained the path of the gallstone was not evident. The surgery was complicated by iatrogenic small bowel injury that required resection and anastomosis in the distal small bowel. There was an intraluminal mass in the proximal bowel, and this segment of bowel had evidence of necrosis and pus. This segment was treated with small bowel resection and anastomosis. The bowel was run from the ligament of Treitz to the cecum and no evidence of further obstruction or diverticula were observed. The abdomen was washed, the fascia was closed, and the skin was left open and treated with negative wound therapy. Due to the length of the procedure and the patient’s age, it was decided that surgery should be discontinued and the right upper quadrant of the abdomen was not explored further.

The pathology report showed that the resected segment, measured 8 cm, contained the gallstone (Figure 4). The stone was an irregular yellow-green calculus measuring 4.0 × 3.1 × 2.5 cm (in greatest dimension), and therefore gallstone ileus was diagnosed. Of note, a formal analysis of the stone itself was not performed. However, it was clinically confirmed by the patient’s history and presentation.

Figure 4

Gallstone (left) and an 8 cm resection of the proximal jejunum (right).

On post-operative day 1, the patient had bloody output from the NG tube and was given intravenous pantoprazole which resolved the reflux. On post-operative day 4, the patient developed mild chest pain; workup revealed a diagnosis of non-ST-elevation myocardial infarction and a troponin level of 9,000 ng/L and brain natriuretic peptide of 15,000 pg/mL. He was medically managed for this due to his acute illness and advanced age, which included a 48-hour heparin drip, aspirin and clopidogrel therapy for at least 1 year, and atorvastatin and metoprolol indefinitely, to be followed on an outpatient basis by a cardiologist. The patient’s chest pain resolved the next day. On post-operative day 5, his NG tube was removed and was started on a clear liquid diet. On post-operative day 6, he was advanced to a low-residue diet. The patient was cleared by the surgery service and was deemed to only necessitate medical management and was turned over to the hospitalist service for monitoring. The patient was discharged on post-operative day 31.

Discussion

This was a case of gallstone ileus complicated by the presence of an intraluminal abscess and perforation. In surgery, when initially entering the abdomen, an iatrogenic circumferential injury occurred to the small bowel; the abdomen was hostile from previous operations making entry and navigation difficult. The development of peritonitis was due to the gallstone applying pressure against the wall of the small bowel causing necrosis and perforation. The patient had a small bowel resection and anastomosis, instead of an enterolithotomy, due to the perforation and small bowel necrosis. The location of the gallstone was also unusual, due to its location in the proximal jejunum, as they are usually found in the terminal ileum.

It is plausible this case might be explained by a classic bowel obstruction in which a loop of small bowel became mechanically strangulated due to adhesions from previous abdominal surgeries. Then, during the small bowel resection, a bezoar was incidentally found. A bezoar was the primary differential diagnosis, as it may have formed due to presence of adhesions, but the patient did not have diverticula on exploration and denied any history of motility problems. This theory may have merit given the fact that gallstone ileus has not been reported to cause bowel obstruction or strangulation. However, bezoars characteristically have a mottled appearance and internal gas bubbles on CT imaging [9] characteristics which were absent in this case. Additionally, consideration of a bezoar was ruled out due to the lack of diverticula necessary for the accumulation and formation of the material; the bowel was thoroughly run through to ensure there were no diverticulum and was intraoperatively confirmed.

If not for the patient’s presentation with peritonitis, the biliary tree may have been visualized with endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography. The problem was that gallstone ileus was not high on the differential. The patient presented with peritonitis and had deteriorated. That is why the diagnostic studies did not include evaluation of the right upper quadrant of the abdomen. The patient was evaluated retrospectively.

Additionally, surgical decision making was difficult. It was not a typical case of gallstone in ileum causing obstruction. This was a clear bowel perforation with abscess formation due to impaction of the gallstone. We were unable to milk the bowel to remove the stone via enterotomy which is the standard care.

In order to understand the significance of a gallstone ileus post cholecystectomy, the classic presentation of gallstone ileus should be considered. For instance, Ozer et al described a 75-year-old male with a classic gallstone ileus, still having his gallbladder [10]. The presentation and diagnostic workup of conventional gallstone ileus can be summarized as being a cause of mechanical small bowel obstruction, most commonly seen in elderly patients. CT being the most sensitive and specific radiological diagnostic method, pathognomonic signs for gallstone ileus include Rigler’s triad, Forchet sign, and Petren sign. Rigler’s triad includes pneumobilia, presence of a gallstone, symptoms indicating small bowel obstruction; Forchet sign referring to “snake head-like appearance” due to accumulation of contrast unable to pass through the obstruction; and Petren sign referring to movement of the contrast agent retrograde from the fistula tract to the gallbladder after oral contrast is administered.

Instances of gallstone ileus post-cholecystectomy have been rarely reported in the literature, as well as pertinent imaging context clues and treatment. For example, a 37-year-old female presented with gallstone ileus 12 months after a cholecystectomy [5]. The authors mention using radiological studies to identify Rigler’s triad, pathognomonic for gallstone ileus. Abdominal CT was considered the best method to visualize the gallstone. Abdominal CT was observed to have a sensitivity of 93%, specificity of 100%, and accuracy of 99%. The authors also confirmed using enterolithotomy as the treatment of choice for gallstone ileus.

Meier et al [2] reported an 87-year-old male with gallstone ileus after a laparoscopic cholecystectomy performed 4 years previously. The authors also performed a systematic review of worldwide publications showing only 49 other cases between 1939 and 2019. There were 49 cases studied, and various mechanisms were considered. The most common mechanism was a lost stone during cholecystectomy which erodes through the intestinal wall leading to the bowel obstruction. It was reported that gallstone ileus could occur anywhere between 10 days to 50 years post-surgery, and a high incidence of gallstone ileus was observed in older females. Proposed mechanisms included an incomplete cholecystectomy, a missed cholecystoenteric fistula during the cholecystectomy, gallstones harbored in the intestinal diverticula, primary gallstones, gallstones trapped in the common bile duct, dislodged gallstones in the intestines that then grow overtime, foreign materials that lead to gallstone formation migration, and otherwise idiopathic mechanisms. It was also noted that the radiological pathognomonic Rigler’s triad was only observed in < 1/3 of cases.

Another case reported an 81-year-old male that presented with gallstone ileus after having a cholecystectomy 25 years previously [6]. The patient had presented with small bowel obstruction and after an exploratory laparotomy gallstone ileus was discovered and removed. This case highlights the importance of keeping gallstone ileus on the differential even after having received a cholecystectomy 2 decades previously. Additionally, laparoscopic-assisted enterolithotomy was proposed as a management for gallstone ileus.

Another case report of an 83-year-old male with a gallstone ileus over 40 years after a cholecystectomy was published whereby the classic symptom of pneumobilia was observed indicating the presence of a bilio-enteric fistula [7].

After 6 years post-operative cholecystectomy, an 89-year-old female presented with gallstone ileus [11]. The authors noted that gallstone ileus can occur without a gallbladder in situ and be a misdiagnosis with fatal consequences if not considered. It demonstrates the importance of actively pursuing and retrieving lost stones during a cholecystectomy, despite being considered a laborious and underappreciated task.

Gallstone ileus is a rare complication following a cholecystectomy. Abdominal CT is the gold standard for diagnosis for gallstone ileus, and enterolithotomy is the operation of choice to remove gallstones. However, our case was complicated by the presence of a small bowel abscess and perforation in the proximal jejunum. Diverticula potentially contribute to the formation of the gallstone, however, no diverticula were found when running the bowel, demonstrating that the gallstone had formed under unusual, challenging circumstances. Our case demonstrates that gallstone ileus can present in unique ways, and that the full differential diagnostic picture needs to be appreciated to avoid adverse pathology and complications of treating gallstone ileus.

In the operating room, it may have been prudent to determine connections between the common bile duct and small bowel. If the patient was stable and younger, right upper quadrant exploration would have been performed and would have led to a more definitive diagnosis (i.e., enteric fistula). If the surgery was elective, the bile ducts may have been evaluated with imaging to delineate the anatomy.

Prospectively, it will be helpful to have an analysis of the gallstone performed to reconcile differing opinions that gallstone ileus may have been a bezoar causing small bowel obstruction rather than a gallstone causing strangulation of the small bowel.

Data Availability

All relevant data are included in this manuscript.

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