Title: Recurrent Gallstone Ileus within Ten Days of Initial Enterolithotomy in an 82 Year Old Female

Author(s): Kaitlyn Patacca, MD; Sarah Heaven, DO; Frances McCarron, MD

Email:  Kpatacca@mercy.com

Introduction: Gallstone ileus is a phenomenon that occurs due to the creation of a biliary-enteric fistula secondary to chronic gallbladder inflammation. Gallstones can enter the enteric tract and cause a small bowel obstruction [1]. Gallstone ileus causes 1-4% of small bowel obstructions, mainly affecting older females [1, 2]. It can be diagnosed on imaging using Rigler’s triad: pneumobilia, small bowel obstruction, and gallstones [3]. Common surgical procedures to address gallstone ileus include enterolithotomy (removing the gallstone via enterotomy), two-stage surgery (primary enterotomy then planned interval cholecystectomy with biliary-enteric fistula take-down), and single stage surgery (enterotomy with cholecystectomy and biliary-enteric fistula take-down during the same procedure) [1,4]. Gallstone ileus is estimated to recur in 5-17% of patients who have a primary enterolithotomy [2]. The average size of stones causing obstruction is 3.6 cm [1].

Case Report(s): An 82-year-old female with past medical history of diabetes mellitus and past abdominal surgical history of hysterectomy presented to the hospital with nausea and emesis. CT imaging revealed small bowel obstruction due to a gallstone from fistulous tract between gallbladder and duodenum. Lab work revealing AKI with Cr of 4.7, normal ALT/AST, normal bilirubin, and no leukocytosis. The patient underwent primary enterolithotomy. On post-operative day three the patient had an endoscopic retrograde pancreatography (ERCP) where sphincterotomy with common bile duct stone extraction and stent placement was performed. The patient did well and was discharged home tolerating a regular diet with plans for eventual elective takedown of biliary-enteric fistula. Two weeks later, the patient presented to the emergency department with recurrent nausea and vomiting. CT with oral contrast revealing recurrent gallstone ileus. The patient underwent exploratory laparotomy, two small bowel resections, take-down of biliary-enteric fistula, subtotal cholecystectomy, modified graham patch repair of duodenum, pyloric exclusion, and gastrojejunostomy. The patient was discharged with the gallbladder fossa drain which was removed at the two-week post-operative visit.

Discussion: Mortality for primary enterolithotomy was 11.7% compared to single-stage surgery at 16.9% [4]. 10% of patients with primary enterolithotomy have recurrent gallstone ileus [4]. It is estimated that 62.6% of the total patients with recurrent gallstone ileus recur within six weeks [1]. Faceted stones account for 83.3% of recurrent gallstone ileus and are a clue that further exploration for additional stones in the bowel might be warranted [1]. Careful consideration of each individual patient is needed to weigh the risks and benefits, given the prevalence of recurrent gallstone ileus in older patients.