A Rocky Situation: Judicious Management of Gallstone Ileus Complicated by Bowel Necrosis and Perforation

Abstract

Gallstone ileus is an uncommon cause of mechanical bowel obstruction, associated with high rates of mortality. This case report details the management of a case of complicated gallstone ileus in a rural setting. A 64 year old male presented to a rural emergency department with acute lower abdominal pain, and was found to be in septic shock with generalised peritonitis. Past history was significant for rheumatoid arthritis on immunosuppression, chronic obstructive pulmonary disease and obesity. Blood tests revealed an elevated bilirubin (45mmol/L) and lactate (2.8mmol/L), whilst Computer Tomography demonstrated Rigler’s triad. The patient was resuscitated and underwent an emergency laparotomy. Intraoperatively, there were multiple areas of full-thickness necrosis and one area of perforation in the distal ileum. A 4cm diameter gallstone was removed from a one metre segment of resected distal ileum. The patient’s haemodynamic instability requiring inotropic support limited the operation to damage control, leaving the remaining small bowel stapled off. The patient was transferred via air ambulance to a tertiary hospital. An end ileostomy was created with a view of re-anastomosis in future. He had an uneventful recovery. This case raises awareness of the rare phenomenon of enteric full-thickness necrosis and perforation associated with gallstone ileus. In the rural setting with limited intensive level care, the less invasive surgical approach is safer. Early communication with the receiving hospital is vital. Due to the paucity in the literature comparing outcomes, there is no consensus on management but should be individualised to the patient’s condition, co-morbidities and healthcare setting.