Hrev_master Abstract Small bowel obstructions are uncommonly due to gallstone ileus. This occurs due to sequelae of cholecystitis in which a chole- cystointestinal fistula forms. Gallstones that pass through the fistu- la can form a mechanical bowel obstruction. Although this entity has been described previously, the complications of surgical man- agement of these patients are less frequently encountered in the lit- erature. This case report highlights one such complication. Introduction Small bowel obstructions are uncommonly due to gallstone ileus. This occurs due to sequelae of cholecystitis in which a chole- cystointestinal fistula forms. Gallstones that pass through the fistu- la can form a mechanical bowel obstruction. Although this entity has been described previously, the complications of surgical man- agement of these patients are less frequently encountered in the lit- erature.1-3 This case report highlights one such complication. Case Report The patient is an 80-year-old female with a medical history of coronary artery disease, ischemic dilated cardiomyopathy, and coronary artery bypass grafting. She presented to the Emergency Department (ED) complaining of abdominal pain and nausea. The pain was described as cramping, severe, and localized around her umbilicus. She denied fevers, diarrhea, and dysuria. Her vital signs included blood pressure at 149/64 mmHg, tem- perature of 37.3°C, pulse of 92 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 98% on room air. She had diffused abdominal tenderness, particularly in the epigas- tric and periumbilical areas. She was otherwise not toxic appear- ing. Her laboratory evaluation showed leukocytosis of 20.6 Thou/uL, while hemoglobin, platelets, renal function, liver func- tion testing, total bilirubin, and lipase were normal. Imaging with Computed Tomography (CT) of the abdomen and pelvis showed findings consistent with a moderate mechanical small bowel obstruction secondary to an intraluminal gallstone in the right lower quadrant at the top of the iliac crest (Figure 1). Air was noted within the lumen of the gallbladder along with pneumobilia, con- sistent with a fistula to the duodenum. Surgical consultation took place, and the patient underwent an enterotomy with extraction of a golf ball-sized gallstone lodged in the mid ileum with proximal bowel dilation. Due to inflammation and risk of common bile duct injury, cholecystectomy was planned in 4 weeks. She did well post-operatively and was discharged home. Two days after being discharged, the patient had a return visit to the ED with worsening abdominal pain and distension. A repeat CT of the abdomen showed an 8mm common bile duct stone near the sphincter of Odie. She underwent endoscopic retro- grade cholangiopancreatography, had papillary stenosis status post sphincterotomy, common bile duct stone extraction, and stent placement. A 3 mm opening at the duodenal bulb was visualized with draining bile consistent with a cholecystoduodenal fistula. Discussion Gallstone ileus is a rare complication of cholelithiasis. Management of gallstone ileus is challenging given the frequent frailty and numerous comorbidities in such patients. This case shows images of the patient’s pathology from CT evaluation.1,2 The pathogenesis of gallstone ileus involves sequelae of chole- cystitis in which a cholecystointestinal fistula forms. Gallstones that pass through the fistula can form a mechanical bowel obstruc- tion. A cholecystoduodenal fistula forms in most cases; however, Emergency Care Journal 2024; volume 20:12857 [Emergency Care Journal 2024; 20:12857] [page 97] Choledocholithiasis during staged surgical management of gallstone ileus: case report John Teijido,1,2 David Fine,1,2 Andrew Konicek1,2 1Emergency Medicine Specialists, S. C., Wauwatosa, Wisconsin; 2Ascension, St. Louis, Missouri, USA Correspondence: John Teijido, Emergency Medicine Specialist, S. C., 10625 West North Avenue, Suite 102, Wauwatosa, WI 53226, USA. Tel.: 414-877-5350 - Fax.: 414-877-5360. E-mail: john.teijido@gmail.com Key words: gallstone ileus, choledocholithiasis, fistula. Contributions: all the authors made a substantive intellectual contri- bution. All the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 26 July 2024. Accepted: 1 September 2024. Early view: 27 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12857 doi:10.4081/ecj.2024.12857 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly cholecystogastric, cholecystojejunal, cholecystoileal, and chole- cystocolonic fistulas have been reported. Passage of the gallstone through the common bile duct, into the gastrointestinal tract, and culminating in a bowel obstruction is extremely rare. This is typi- cally associated with patients at risk of developing gastrointestinal strictures, such as those with Crohn’s disease.3,4 Mirizzi syndrome and gallstone ileus are frequently coexistent as they represent different pathologies of the same disease process. Mirizzi syndrome is extrinsic compression of the common bile duct due to impacted gallstones in the gallbladder infundibulum or the cystic duct. Impacted gallstones then lead to ischemia and necrosis of the gallbladder wall, which can result in fistula forma- tion with nearby structures.5-7 The clinical evaluation typically involves signs and symptoms of a bowel obstruction. A high-grade obstruction may be noted; however, various stages of a bowel obstruction may be encoun- tered depending on the chronicity of symptoms. Abdominal disten- sion, nausea, vomiting, and obstipation may be noted. Physical exam findings will not provide specificity for the diagnosis of gall- stone ileus. However, the Mordor triad (history of known gall- stones, clinical signs of cholecystitis, and onset of bowel obstruc- tion) may be noted and should point to gastrointestinal pathology, rather than adhesion or incarcerated hernia, causing the patient’s symptoms.8,9 Diagnostic testing in the form of cross-sectional imaging is most sensitive and specific for gallstone ileus. Ultrasonography may be considered if CT imaging is not available as it may also reveal the exact location of the obstructing gallstone. X-ray will be nonspecific and may only show signs of a small bowel obstruction without revealing the underlying cause.10-12 Laboratory testing of liver enzymes and bilirubin concentration is often not revealing. Contrast-enhanced CT has high sensitivity and specificity at 93% and 100% respectively.13 Treating gallstone ileus requires surgical management. A two- stage approach is common; however, in selected patients, a one- stage procedure may be considered. The persistence of a cholecys- tointestinal fistula, as the two-stage approach involves first stone extraction followed later by fistula closure, portends a risk of ret- rograde cholecystitis, gallbladder cancer, and recurrent gallstone ileus. However, A study in 1994 showed higher mortality in the one-stage approach given the higher degree of invasiveness. Patients’ pre-surgical morbidity is important in surgical decision- making.14 Conclusions Gallstone ileus is an uncommon cause of bowel obstruction. CT imaging frequently yields impressive images as demonstrated in this case. Emergency providers need to consider this diagnosis when patients present with signs and symptoms of cholelithiasis and bowel obstruction. Furthermore, when the two-stage surgical management approach is taken, complications of recurrent chole- cystitis, biliary cancer, and recurrent complications related to gall- bladder calculi should be anticipated. References 1. Halabi WJ, Kang CY, Ketana N, et al. Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Ann Surg 2014;259:329-35. 2. Abou-Saif A, Al-Kawas FH. Complications of gallstone dis- ease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J Gastroenterol 2002;97:249-54. 3. Clavien PA, Richon J, Burgan S, et al. Gallstone ileus. Br J Surg1990;77:737-42. 4. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg 1994;60:441-6. Case Report [page 98] [Emergency Care Journal 2024; 20:12857] Figure 1. a) Computed Tomography (CT) image depicting findings of mildly dilated loops of small bowel and an intraluminal gallstone (blue circle); b) Separate coronal image showing a contracted gallbladder with luminal air (blue circle) and pneumobilia (green circle). Non -co mmerc ial us e o nly 5. Beltran MA, Csendes A. Mirizzi syndrome and gallstone ileus: an unusual presentation of gallstone disease. J Gastrointest Surg 2005:9:686-9. 6. Csendes A, Díaz JC, Burdiles P, et al. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg 1989;76:1139-43. 7. Yip AW, Chow WC, Chan J, Lam KH. Mirizzi syndrome with cholecystocholedochal fistula: preoperative diagnosis and management. Surgery 1992;111:335-8. 8. Beuran M, Ivanov I, Venter MD. Gallstone ileus-clinical and therapeutic aspects. J Med Life 2010;3:365-71. 9. Beuran M, Venter MD, Ivanov I, et al. Iftimie-Nastase I and Venter DP. 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