Gallstone Ileus following Endoscopic Stone Extraction

Abstract

An 85-year-old woman was an outpatient treated at Tokyo Rosai Hospital for cirrhosis caused by hepatitis B. She had previously been diagnosed as having common bile duct stones, for which she underwent endoscopic retrograde cholangiopancreatography (ERCP). However, as stone removal was unsuccessful, a plastic stent was placed after endoscopic sphincterotomy. In October 2012, the stent was replaced endoscopically because she developed cholangitis due to stent occlusion. Seven days later, we performed ERCP to treat recurring cholangitis. During the procedure, the stone was successfully removed by a balloon catheter when cleaning the common bile duct. The next day, the patient developed abdominal pain, abdominal distension, and nausea and was diagnosed as having gallstone ileus based on abdominal computed tomography (CT) and abdominal ultrasonography findings of an incarcerated stone in the terminal ileum. Although colonoscopy was performed after inserting an ileus tube, no stone was visible. Subsequent CT imaging verified the disappearance of the incarcerated stone from the ileum, suggesting that the stone had been evacuated naturally via the transanal route. Although it is extremely rare for gallstone ileus to develop as a complication of ERCP, physicians should be aware of gallstone ileus and follow patients carefully, especially after removing huge stones.

Gallstone Ileus Caused by Cholecystocolonic Fistula and Gallstone Impaction in the Sigmoid Colon: Review of the Literature and Novel Surgical Treatment with Trephine Loop Colostomy

“…Proximal migration or direct invasion to the stomach can result in the stone causing gastric outlet obstruction (Bouveret syndrome) [ 13 ] or being vomited [ 14 ]. The passage of gallstones large enough to cause obstruction is also reported following endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy [ 15 ]. Once the gallstone has passed into the gastrointestinal tract, risk factors for impaction are hypothesized to be (1) if the stone is more than 2.5 cm [ 10 ], (2) if peristalsis carries the stone to a competent ileocaecal valve [ 5 ], and (3) if there is presence of co-existing disease such as malignancy, strictures, diverticulum, or sites of previous surgery or anastamoses [ 9 , 16 , 17 , 18 , 19 ].…”

Recurrent gallstone ileus due to a residual gallstone: A case report and literature review

“…Recurrence almost always occurs as a result of residual stones in the proximal bowel or gallbladder and gallstones ≥2 cm are most likely to obstruct [6,9] . Recurrence is also reported following ERCP and endoscopic laser lithotripsy of obstructing duodenal gallstones (Bouveret’s syndrome) [11,12] . The mainstay of preventing recurrence is to take meticulous efforts pre-operatively and intra-operatively to identify and remove stones ≥2 cm.…”

Gallstone ileus following therapeutic endoscopic retrograde cholangiopancreatography

“…There are 13 cases of gallstone ileus following ERCP in the literature . In the majority, the calculi were retrieved from the common bile duct during ERCP, and left in the small bowel lumen, subsequently causing obstruction.…”

“…The time of obstruction varied from 1 day to 4 months after the procedure. The most common site of impaction is the ileum, due to its smaller diameter, tortuosity and less active peristalsis . Furthermore, factors that slow intestinal peristalsis or narrow the bowel may increase the risk of gallstone ileus, including ascites, decreased physical activity, radiation enteritis or anastomotic strictures …”

“…The size of the calculi in these cases ranged from 2 to 3.1 cm. It is, however, noted that two cases of gallstone ileus following ERCP have been managed conservatively with success, with calculi measuring up to 2 cm. One death was reported from gallstone ileus after ERCP, due to an anastomotic leak after small bowel resection …”