Hrev_master [Emergency Care Journal 2017; 13:6518] [page 19] Investigating a rare cause of intestinal occlusion Bahjat Barakat,1 Raffaele Pezzilli2 1Emergency Department; 2Department of Digestive Diseases, Sant’Orsola-Malpighi Hospital, Bologna Italy Abstract Gallstone ileus is a rare form of mechanical intestinal obstruction caused by the passage of gallstones in the gastroin- testinal lumen and is often diagnosed in eld- erly females. Diagnosis can be difficult due to nonspecific findings during physical examination and there are a number of options regarding surgical or endoscopic treatment. We report the rare case of a 77- year-old female patient with gastrointestinal obstruction due to a gallstone, but without a cholecystointestinal fistula. Clinicians should be aware of this rare entity especial- ly in emergency situations, as early diagno- sis and appropriate subsequent therapy in such cases is essential to reduce mortality. Introduction Gallstone ileus is a rare form of mechanical intestinal obstruction caused by the passage of gallstones in the gastroin- testinal lumen, which is often present in eld- erly females. Diagnosis can be difficult due to nonspecific findings during physical examination and there are a number of options regarding surgical or endoscopic treatment. We report the rare case of a 77- year-old female patient with gastrointestinal obstruction due to a gallstone, but without a cholecystointestinal fistula. Clinicians should be aware of this rare entity especial- ly in emergency situations, as early diagno- sis and appropriate therapy is vital since the mortality rate is at present of about 7%.1,2 Case Report A 77-year-old female patient was admitted to our Emergency Room (ER) due to persistent biliary vomiting which had continued for four days. She had previously been treated with metoclopramide but with no benefit. Her past medical history revealed the following conditions: high blood pressure which had been chronically treated with beta-blockers, hypercholes- terolemia in statin therapy, hypothyroidism treated with levothyroxine, chronic obstruc- tive pulmonary disease, hiatal hernia and the presence of gallstones diagnosed after a gallbladder attack three years before admis- sion. She had declined surgery for this last condition. On admission, her arterial blood pressure was 130/70 mmHg, heart rate 100 bpm and O2 saturation was 94%. She was afebrile and was suffering from constipa- tion and had not passed stools for four days. Physical examination of the abdomen wors- ened epigastric pain without signs of peri- tonitis and both cardiac and pulmonary examinations were unremarkable. Blood tests revealed lekocytosis (WBC 13390 mmc), C-reactive protein 1.9 mg/dL, creati- nine of 2.2 mg/dL, urea 105 mg/dL, total bilirubin 1.4 mg/dL, AST 103 IU/L (upper normal limit 35) and ALT 91 IU/L (upper normal limit 35). She was treated with i.v. fluids in the ER. An abdominal x-ray was carried out showing the presence of gastrectasia, patho- logical dilation of small bowel loops with air-fluid levels and presence of a faintly radiopaque image in the intestinal loop (Figure 1). An ultrasonography was carried out confirming the picture to be compatible with gastrectasia, a small bowel obstruction (Figure 2A) and one large gallstone (Figure 2B). In order to better define the findings of the two previous imaging techniques which were carried out, the patient underwent computer tomography which revealed the presence of air in the biliary tree, a small bowel obstruction due to the presence of huge ring calcification 3.5 cm in diameter in the lumen of the proximal dilated jejunum loop (Figure 3); the gallbladder was not dis- tended and there were both a gallstone and air inside it (Figure 3); there was no evi- dence of cholecysto-enteric fistula. The patient underwent surgery and during the operation a small enterotomy was per- formed and a gallstone in the jejunum was found and extracted. No cholecystectomy was performed and exploratory examina- tion of the gallbladder did not reveal the presence of any fistula. The patient was then admitted to the Intensive Care Unit due to uncontrolled blood pressure and ST alter- ation at ECG without troponin alteration. The patient was discharged after 10 days in good general health. Discussion Intestinal occlusion due to migration of large gallstones is a rare event affecting mainly older females (female-male ratio of 4.5:1) who usually suffer from other comor- bidities.1,3 It has also been reported that the incidence of gallstone ileus is 0.095% which is a lower percentage than that reported in the past.1 Clinical diagnosis is sometimes difficult as in our present case. The onset symptoms related to gallstone ileus are non-specific, namely, nausea, vomiting and vague abdominal pain as in our case are usually present; occasional acute abdominal pain and distention may also be present.4,5 Preoperative diagnosis is carried out in the majority of cases (about 80%) from a combination of ultrasonography and com- puted tomography scans1 as we have report- ed. We should be aware that a differential diagnosis is essential as this condition may mimick other more frequent diseases such as bezoars, foreign bodies or malignancies.6 From a radiological point of view, some authors have claimed the presence of an imaging triad, known as Rigler’s triad, which consists in the presence of gas in the biliary tree, small bowel obstruction and the presence of a gallstone inside the bowel lumen.7 The dimension of an impacted intestinal stone is 3.6 cm with a range from 2.5 to 4.5 cm, the location commonly being in the terminal ileum, whereas, as however occurred in our case, it is rarely localized in the jejunum.1 The pathogenesis of gallstone ileus is the presence of a cholecystoenteric fistula which is commonly located at the level of terminal ileum.8 In very rare cases cholecystoenteric fistulas are absent as in the case we have reported.9 Surgical treat- ment of large stones is still controversial; current surgical procedures are simple enterolithotomy or enterolithotomy, chole- cystectomy and fistula closure in a one- stage procedure or enterolithotomy with Emergency Care Journal 2017; volume 13:6518 Correspondence: Raffaele Pezzilli, Department of Digestive Diseases, Sant’Orsola-Malpighi Hospital, Bologna, Italy. Phone: +39-051244148 - Fax: +39-0512144148. E-mail: raffaele.pezzilli@aosp.bo.it Key words: Computed tomography; Gallstones; Intestinal Occlusion; Ultrasonography. Funding: the authors disclosed no financial relationships relevant to this publication. Received for publication: 23 December 2016. Revision received: 30 March 2017. Accepted for publication: 3 April 2017. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright B. Barakat and R. Pezzilli, 2017 Licensee PAGEPress, Italy Emergency Care Journal 2017; 13:6518 doi:10.4081/ecj.2017.6518 Non co mmerc ial us e o nly [page 20] [Emergency Care Journal 2017; 13:6518] cholecystectomy performed later; bowel resection may be necessary in certain cases after enterolithotomy is performed.2,10 In recent years, in cases of stones locat- ed in the jejunum or in the colon, endoscop- ic treatment with extraction of the stone may be carried out with or without extracor- poreal shock wave lithotripsy to fragment the stones.11 Conclusions In conclusion, we have reported a chal- lenging case of small bowel obstruction due to a gallstone located in the jejunum with- out radiological and surgical evidence of a cholecystoenteric fistula. Due to a lack of specific symptoms, a preoperative study based on imaging techniques is the corner- stone of treatment, which has been tailored especially for patients with comorbidities. References 1. Halabi WJ, Kang CY, Ketana N, et al. Surgery for gallstone ileus: a nation- wide comparison of trends and out- comes. Ann Surg 2014;259:329-35. 2. Nuño-Guzmán CM, Marín-Contreras ME, Figueroa-Sánchez M, Corona JL. Gallstone ileus, clinical presentation, diagnostic and treatment approach. World J Gastrointest Surg 2016;8:65- 76. 3. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007;31:1292-7. 4. Day EA, Marks C. Gallstone ileus. Review of the literature and presenta- tion of thirty-four new cases. Am J Surg 1975;129:552-8. 5. Sahsamanis G, Maltezos K, Dimas P, et al. Bowel obstruction and perforation due to a large gallstone. A case report. Int J Surg Case Rep 2016;26:193-6. 6. Milanchi S, McVay C, Fermelia DE. Jejunal enterolith causing small-bowel obstruction. J Am Coll Surg 2007;205: 377. 7. Gaduputi V, Tariq H, Rahnemai-Azar AA, et al. Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret's syndrome. World J Gastrointest Surg 2015;7:394-7. 8. Chatterjee S, Chaudhuri T, Ghosh G, Ganguly A. Gallstone ileus: an atypical presentation and unusual location. Int J Surg 2008;6:e55-6. 9. Abtar HK, Mneimneh M, Hammoud MM, et al. Primarily proximal jejunal stone causing enterolith ileus in a patient without evidence of cholecys- toenteric fistula or jejunal diverticulo- sis. Case Rep Surg 2016;2016:8390724. 10. Sahsamanis G, Maltezos K, Dimas P, et al. Bowel obstruction and perforation due to a large gallstone. A case report. Int J Surg Case Rep 2016;26:193-6. 11. Pezzoli A, Maimone A, Fusetti N, Pizzo E. Gallstone ileus treated with non-sur- gical conservative methods: a case report. J Med Case Rep 2015;9:15. Case Report Figure 2. External abdominal ultrasonography. A) Dilation of small bowel loops asso- ciated with bowel wall thickness, presence of fluid-fluid levels and thickness of valvu- lae conniventes; B) presence of large gallstone. Figure 3. Computer tomography of the abdomen showing the presence of bowel obstruction (star) due to the presence of huge ring calcification 3.5 cm in diameter in the proximal dilated jejunum loop (arrowhead); the gallbladder was not distended and there were both a gallstone and air inside it (arrow). Figure 1. Abdominal x-ray showing the pres- ence of gastrectasia (star), pathological dila- tion of small bowel loops with air-fluid levels (arrow) and of a faintly radiopaque image (arrowhead). Non co mmerc ial us e o nly