Correspondence

Large Gall Bladder Stone Causing Mid Small Bowel Obstruction with Cholecystoduodenal Fistula

B Kaur*, A Gogia**, A Kakar**, SP Byotra**, BB Aggarwal+

*Postgraduate; **Consultants, Department of Medicine; +Consultant, Department of Surgery; Sir Ganga Ram Hospital, New Delhi - 110 060. Received : 22.1.2008; Revised : 18.8.2008; Accepted : 4.9.2008

Sir,

A 75 years gentleman presented to us with complaints of pain in abdomen, recurrent vomiting, and absolute constipation for a period of 7 days. Patient was a known case of diabetes mellitus, hypertension and coronary artery disease. Abdominal examination showed diffuse tenderness and absent bowel sounds. Upper GI endoscopy done prior to admission revealed duodenal ulcer. X-ray

abdomen (erect) showed multiple air fluid levels with pneumobilia and supine view showed large stone (Fig. 1). CECT abdomen revealed enterolith in mid small bowel with proximal jejunal obstruction with collapsed thick walled gall bladder with pneumobilia (Fig. 2) and cholecystoduodenal fistula. Laparoscopy revealed inflamed gut, 5 cms stone was extracted from the ileum and resection was done.

Gallstone ileus is rare and is associated with a mortality rate of 20%.1 The formation of a cholecystoenteric fistula after an acute cholecystitis episode allows the gallstone to pass into the bowel. Sometimes the stone passes through, but more often it causes an obstruction the terminal ileum and the ileocecal valve.2 Gallstone ileus accounts for about 1–3% of cases of intestinal obstruction, but it is becoming more common as the average age of the population increases.3 Clinical symptoms of gallstone ileus are nonspecific. It is primarily a disease of elderly women. Signs to look out on sonography and CT are the disappearance of a previously visible gallbladder, air or contrast medium in the biliary tree or gallbladder stone, a calcified intraluminal mass and an ileus.

REFERENCES

  1. Mühlmann, Gilbert, et al. Gallstone Ileus: Rare and Still Controversial. Kirchmayr, Werner. Anz J of Surgery 2005;75: 234-8.
  2. Reisner RM, Cohen JR. Gallstone ileus: A review of 1001 reported cases. Am Surg 1994;60:441-6.
  3. Al-Obaid O. Gallstone Ileus: A forgotten rare cause of intestinal obstruction. Saudi J Gastroenterol 2007;13:39-42.