Gallstone ileus following therapeutic endoscopic retrograde cholangiopancreatography

Abstract

An 81-year-old man presented with a 1 day history of epigastric and right upper quadrant pain, with altered liver function tests (LFTs). His past history included a laparoscopic cholecystectomy 7 years ago, and an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy 2 years ago for choledocholithiasis. There was no history of any other abdominal surgery. In the last 5 years, he had been diagnosed with a protein-losing enteropathy after extensive investigation for iron deficiency anaemia and loss of weight. His other co-morbidities were stable ischaemic heart disease and hypertension.On presentation, he had features of sepsis with hypotension and mild hypothermia. His initial blood tests showed markedly deranged LFTs (bilirubin 55 μmol/L, alkaline phosphatase 1046 U/L and gammaglutamyl transferase 805 U/L), with raised inflammatory markers (white cell count 14.5 × 10 9 /L, neutrophils 12.0 × 10 9 /L and CRP 110 mg/L). He was clinically diagnosed with ascending cholangitis. Fluid resuscitation and broad spectrum intravenous antibiotic therapy were initiated.An abdominal computed tomography (CT) scan was performed, which clearly demonstrated choledocholithiasis, with no other source of sepsis (Fig. 1, left). A magnetic resonance cholangiopancreatography (MRCP) confirmed a dilated common bile duct (CBD) (1.9 cm) with three large intraductal calculi. The patient went on to have an urgent ERCP, sphincterotomy and stone removal (Fig. 1, inset). Multiple stones were removed, reported to be between 2 and 3 cm in size. Over the next 2 days, he improved clinically and his LFTs began to normalize.Over the subsequent 4 days, he developed progressive abdominal distension with eventual obstipation and vomiting. An abdominal X-ray revealed multiple dilated small bowel loops with air fluid levels and pneumobilia in keeping with a small bowel obstruction and recent ERCP. A CT scan with contrast confirmed a small bowel obstruction with a transition point suggestive of an occluding mid-

Delayed presentation of gallstone ileus due to spilled gallstones: A case report

“…Very few cases of gallstone ileus are identified in cholecystectomized patients in the absence of a fistula. Narasimhan et al describe a case of gallstone ileus as a rare complication following an endoscopic retrograde cholangiopancreatography (ERCP) [13]. Draganic et al and Zamora et al describe cases of a gallstone eroding through the bowel wall only a few months following a laparoscopic cholecystectomy with spilled stones [14,15].…”