- Email: [email protected]
A Rolling Stone
The American Journal of Medicine (2007) 120, 772-774
DIAGNOSTIC DILEMMA: GASTROENTEROLOGY Charles M. Wiener, MD, Section Editor
A Rolling Stone Marco A. Gonzalez, MD,a Joseph J. Sorrento, MD,b Ernest Tsao, MDc Department of aSurgery and cDepartment of Medicine, Division of Gastroenterology-Hepatology, Stony Brook University Medical Center, Stony Brook, NY and bDepartment of Surgery, Northport Veterans Affairs Medical Center, Northport, NY.
PRESENTATION In this case, seemingly ordinary symptoms were traced to an unusual source. A 73-year-old male presented to the emergency department with a 5-day history of poorly localized, intermittent abdominal pain that was unrelated to meals. Associated symptoms included nausea, diarrhea, and progressive abdominal distention, which prompted him to seek medical care. He denied any history of fever, chills, vomiting, or unintentional weight loss. The patient’s past medical history was significant for hypertension, coronary artery disease, type-2 diabetes mellitus, and dyslipidemia. His only surgical history was a left inguinal hernia repair. Four weeks earlier, a computed tomography scan of the abdomen and pelvis, performed for an unrelated condition, disclosed asymptomatic cholelithiasis.
ASSESSMENT On physical examination, distention of the patient’s abdomen, hyperactive bowel sounds, and generalized tenderness to palpation were noted. His cardiopulmonary examination was unremarkable, vital signs were normal, and results of laboratory testing, including a white blood cell count, liver function tests, and amylase and lipase levels, were all within normal limits. An abdominal x-ray revealed dilated loops of bowel with air fluid levels plus air in the biliary tree. A computed tomography scan of the abdomen and pelvis demonstrated air within the gallbladder and a calcified intraluminal mass in the descending and sigmoid colon (Figure 1). Of significance was the absence of a large gallstone in the gallbladder, which had been visible on a computed tomography scan that was obtained 4 weeks earlier (Figure 2). Although colonic obstruction from a gallstone is very rare, accounting for only 2% to 8% of all cases of gallstone ileus, the Requests for reprints should be addressed to Ernest Tsao, MD, Stony Brook University Medical Center, Division of Gastroenterology-Hepatology, Health Science Center, T-17, Room 060, Stony Brook, NY 11794. E-mail address: [email protected]
0002-9343/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2007.06.018
diagnosis of colonic gallstone ileus was considered, based on the computed tomography findings.1
DIAGNOSIS Colonoscopy, carried out with informed consent, confirmed the presence of an obstructed gallstone in the sigmoid colon (Figure 3). Gallstone ileus is an unusual source of gastrointestinal obstruction, and it is associated with an 8% rate of morbidity and mortality, the result of delayed diagnosis and patient comorbidities.2 Furthermore, an increased incidence is seen in patients older than 65 years. Many of these patients will have concomitant cardiovascular disease, diabetes, or morbid obesity at the time of diagnosis.1 Gallstone ileus is caused by fistula formation and subsequent stone migration from the gallbladder or less frequently, the common bile duct. Fistula formation occurs when the gallbladder ruptures into adjacent bowel or when a large stone produces direct-pressure necrosis of the gallbladder wall. In the presence of a cholecystoduodenal or cholecystogastric fistula, the most common site of intestinal obstruction is at the terminal ileum. Other sites of obstruction, in order of decreasing frequency, include the proximal ileum, jejunum, and duodenum.2,3 Colonic obstruction can be brought about by a cholecystocolic or cholecystoduodenocolic fistula.3 Blockage usually occurs in the sigmoid colon. These patients typically have concomitant diverticular disease or carcinoma at the point of impaction.4 Among those who have a normal colon without underlying disease—like our patient— obstruction can still occur when the gallstone is greater than 2.5 cm. Smaller stones have been reported to cause obstruction in the presence of fecal impaction.3,4 Patients generally present with intermittent episodes of abdominal pain, vomiting, and diarrhea, reflecting temporary blockage by the stone and ensuing dislodgment, as it traverses distally in the bowel, a phenomenon known as tumbling obstruction.5 Plain abdominal films can be helpful in the diagnosis of gallstone ileus. Classic findings include pneumobilia, evidence of intestinal obstruction, and an ab-
Gonzalez et al
A Rolling Stone
773
Figure 3 Figure 1 Contrast enhanced abdominal computed tomography was performed upon admission. The arrow shows a calcified mass (arrow) in the descending and sigmoid colon, which caused proximal colonic dilatation.
errantly-located gallstone, often seen with the aid of an oral contrast.3,5 Computed tomographic imaging of the abdomen may show pneumobilia and the site of obstruction within the gastrointestinal tract. Laboratory findings are usually nonspecific and might include slight leukocytosis, electrolyte imbalance, and evidence of dehydration.5
MANAGEMENT Multiple attempts to extract the stone endoscopically were unsuccessful, and the patient had to be taken to the operat-
Figure 2 Four weeks before admission, contrast enhanced abdominal computed tomography revealed a large gallstone (arrow) within the gallbladder.
A large gallstone was found during colonoscopy.
ing room for exploratory laparotomy. During the procedure, a serosal tear was observed in the sigmoid colon where the gallstone was lodged. Since the stone could not be manually milked into the rectum, an enterolithotomy was performed with extraction of a large gallstone, measuring 5.8- ⫻ 4.2- ⫻ 3.3 cm (Figures 4 and 5). The gallstone appeared to have passed through a cholecystocolic fistula, which was found between the gallbladder and the ascending colon with surrounding fibrosis and inflammation. After the fistula was repaired, a partial cholecystectomy was performed, along with a right hemicolectomy and a temporary diverting ileostomy. The patient’s postoperative recovery was uneventful, and reversal of the ileostomy was planned. Because spontaneous passage of the stone is rare, emergent surgical intervention remains the treatment of choice for stone extraction and relief of obstruction.3,6 This usually entails enterolithotomy, with or without cholecystectomy, and takedown of the cholecystoenteric fistula.7 Bowel resection is sometimes necessary, particularly in the presence
Figure 4 Emergent laparotomy with enterolithotomy was the procedure of choice.
774
The American Journal of Medicine, Vol 120, No 9, September 2007
References
Figure 5
The gallstone was removed.
of a perforated bowel. There have been reports of successful endoscopic removal of an obstructing colonic gallstone by colonoscopy.8,9 Shock-wave lithotripsy also has been used successfully in treating patients who were not candidates for surgery.10
1. O’Donoghue GT, Winter D, Deasy J. Image of the month. Cholecystocolic fistula and large-bowel obstruction due to gallstone ileus. Arch Surg. 2003;138:1391-1392. 2. Ishikura H, Sakata A, Kimura S, et al. Gallstone ileus of the colon. Surgery. 2005;138:540-542. 3. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg. 1990;77:737-742. 4. Anseline P. Colonic gall-stone ileus. Postgrad Med J. 1981;57:62-65. 5. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60:441-446. 6. Anagnostopoulos GK, Sakorafas G, Kolettis T, et al. A case of gallstone ileus with an unusual impaction site and spontaneous evacuation. J Postgrad Med. 2004;50:55-56. 7. Pavlidis TE, Atmatzidis KS, Papaziogas BT, Papaziogas TB. Management of gallstone ileus. J Hepatobiliary Pancreat Surg. 2003; 10:299-302. 8. Roberts SR, Chang C, Chapman T, et al. Colonoscopic removal of a gallstone obstructing the sigmoid colon. J Tenn Med Assoc. 1990;83: 18-19. 9. Zaretzky B, Kodsi BE, Iswara K. Colonoscopic diagnosis and relief of large bowel obstruction caused by impacted gallstone. Gastrointest Endosc. 1977;23:210-211. 10. Holl J, Sackmann M, Hoffmann R, et al. Shock-wave therapy of gastric outlet syndrome caused by a gallstone. Gastroenterology. 1989; 97:472-474.
DIAGNOSTIC DILEMMA: GASTROENTEROLOGY Charles M. Wiener, MD, Section Editor
A Rolling Stone Marco A. Gonzalez, MD,a Joseph J. Sorrento, MD,b Ernest Tsao, MDc Department of aSurgery and cDepartment of Medicine, Division of Gastroenterology-Hepatology, Stony Brook University Medical Center, Stony Brook, NY and bDepartment of Surgery, Northport Veterans Affairs Medical Center, Northport, NY.
PRESENTATION In this case, seemingly ordinary symptoms were traced to an unusual source. A 73-year-old male presented to the emergency department with a 5-day history of poorly localized, intermittent abdominal pain that was unrelated to meals. Associated symptoms included nausea, diarrhea, and progressive abdominal distention, which prompted him to seek medical care. He denied any history of fever, chills, vomiting, or unintentional weight loss. The patient’s past medical history was significant for hypertension, coronary artery disease, type-2 diabetes mellitus, and dyslipidemia. His only surgical history was a left inguinal hernia repair. Four weeks earlier, a computed tomography scan of the abdomen and pelvis, performed for an unrelated condition, disclosed asymptomatic cholelithiasis.
ASSESSMENT On physical examination, distention of the patient’s abdomen, hyperactive bowel sounds, and generalized tenderness to palpation were noted. His cardiopulmonary examination was unremarkable, vital signs were normal, and results of laboratory testing, including a white blood cell count, liver function tests, and amylase and lipase levels, were all within normal limits. An abdominal x-ray revealed dilated loops of bowel with air fluid levels plus air in the biliary tree. A computed tomography scan of the abdomen and pelvis demonstrated air within the gallbladder and a calcified intraluminal mass in the descending and sigmoid colon (Figure 1). Of significance was the absence of a large gallstone in the gallbladder, which had been visible on a computed tomography scan that was obtained 4 weeks earlier (Figure 2). Although colonic obstruction from a gallstone is very rare, accounting for only 2% to 8% of all cases of gallstone ileus, the Requests for reprints should be addressed to Ernest Tsao, MD, Stony Brook University Medical Center, Division of Gastroenterology-Hepatology, Health Science Center, T-17, Room 060, Stony Brook, NY 11794. E-mail address: [email protected]
0002-9343/$ -see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2007.06.018
diagnosis of colonic gallstone ileus was considered, based on the computed tomography findings.1
DIAGNOSIS Colonoscopy, carried out with informed consent, confirmed the presence of an obstructed gallstone in the sigmoid colon (Figure 3). Gallstone ileus is an unusual source of gastrointestinal obstruction, and it is associated with an 8% rate of morbidity and mortality, the result of delayed diagnosis and patient comorbidities.2 Furthermore, an increased incidence is seen in patients older than 65 years. Many of these patients will have concomitant cardiovascular disease, diabetes, or morbid obesity at the time of diagnosis.1 Gallstone ileus is caused by fistula formation and subsequent stone migration from the gallbladder or less frequently, the common bile duct. Fistula formation occurs when the gallbladder ruptures into adjacent bowel or when a large stone produces direct-pressure necrosis of the gallbladder wall. In the presence of a cholecystoduodenal or cholecystogastric fistula, the most common site of intestinal obstruction is at the terminal ileum. Other sites of obstruction, in order of decreasing frequency, include the proximal ileum, jejunum, and duodenum.2,3 Colonic obstruction can be brought about by a cholecystocolic or cholecystoduodenocolic fistula.3 Blockage usually occurs in the sigmoid colon. These patients typically have concomitant diverticular disease or carcinoma at the point of impaction.4 Among those who have a normal colon without underlying disease—like our patient— obstruction can still occur when the gallstone is greater than 2.5 cm. Smaller stones have been reported to cause obstruction in the presence of fecal impaction.3,4 Patients generally present with intermittent episodes of abdominal pain, vomiting, and diarrhea, reflecting temporary blockage by the stone and ensuing dislodgment, as it traverses distally in the bowel, a phenomenon known as tumbling obstruction.5 Plain abdominal films can be helpful in the diagnosis of gallstone ileus. Classic findings include pneumobilia, evidence of intestinal obstruction, and an ab-
Gonzalez et al
A Rolling Stone
773
Figure 3 Figure 1 Contrast enhanced abdominal computed tomography was performed upon admission. The arrow shows a calcified mass (arrow) in the descending and sigmoid colon, which caused proximal colonic dilatation.
errantly-located gallstone, often seen with the aid of an oral contrast.3,5 Computed tomographic imaging of the abdomen may show pneumobilia and the site of obstruction within the gastrointestinal tract. Laboratory findings are usually nonspecific and might include slight leukocytosis, electrolyte imbalance, and evidence of dehydration.5
MANAGEMENT Multiple attempts to extract the stone endoscopically were unsuccessful, and the patient had to be taken to the operat-
Figure 2 Four weeks before admission, contrast enhanced abdominal computed tomography revealed a large gallstone (arrow) within the gallbladder.
A large gallstone was found during colonoscopy.
ing room for exploratory laparotomy. During the procedure, a serosal tear was observed in the sigmoid colon where the gallstone was lodged. Since the stone could not be manually milked into the rectum, an enterolithotomy was performed with extraction of a large gallstone, measuring 5.8- ⫻ 4.2- ⫻ 3.3 cm (Figures 4 and 5). The gallstone appeared to have passed through a cholecystocolic fistula, which was found between the gallbladder and the ascending colon with surrounding fibrosis and inflammation. After the fistula was repaired, a partial cholecystectomy was performed, along with a right hemicolectomy and a temporary diverting ileostomy. The patient’s postoperative recovery was uneventful, and reversal of the ileostomy was planned. Because spontaneous passage of the stone is rare, emergent surgical intervention remains the treatment of choice for stone extraction and relief of obstruction.3,6 This usually entails enterolithotomy, with or without cholecystectomy, and takedown of the cholecystoenteric fistula.7 Bowel resection is sometimes necessary, particularly in the presence
Figure 4 Emergent laparotomy with enterolithotomy was the procedure of choice.
774
The American Journal of Medicine, Vol 120, No 9, September 2007
References
Figure 5
The gallstone was removed.
of a perforated bowel. There have been reports of successful endoscopic removal of an obstructing colonic gallstone by colonoscopy.8,9 Shock-wave lithotripsy also has been used successfully in treating patients who were not candidates for surgery.10
1. O’Donoghue GT, Winter D, Deasy J. Image of the month. Cholecystocolic fistula and large-bowel obstruction due to gallstone ileus. Arch Surg. 2003;138:1391-1392. 2. Ishikura H, Sakata A, Kimura S, et al. Gallstone ileus of the colon. Surgery. 2005;138:540-542. 3. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg. 1990;77:737-742. 4. Anseline P. Colonic gall-stone ileus. Postgrad Med J. 1981;57:62-65. 5. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60:441-446. 6. Anagnostopoulos GK, Sakorafas G, Kolettis T, et al. A case of gallstone ileus with an unusual impaction site and spontaneous evacuation. J Postgrad Med. 2004;50:55-56. 7. Pavlidis TE, Atmatzidis KS, Papaziogas BT, Papaziogas TB. Management of gallstone ileus. J Hepatobiliary Pancreat Surg. 2003; 10:299-302. 8. Roberts SR, Chang C, Chapman T, et al. Colonoscopic removal of a gallstone obstructing the sigmoid colon. J Tenn Med Assoc. 1990;83: 18-19. 9. Zaretzky B, Kodsi BE, Iswara K. Colonoscopic diagnosis and relief of large bowel obstruction caused by impacted gallstone. Gastrointest Endosc. 1977;23:210-211. 10. Holl J, Sackmann M, Hoffmann R, et al. Shock-wave therapy of gastric outlet syndrome caused by a gallstone. Gastroenterology. 1989; 97:472-474.