Gallstone ileus after hepaticojejunostomy in liver transplant recipient: case report

Abstract

Presenter: Patricio Vanerio MD | Hospital Central de las Fuerzas Armadas Background: Gallstone ileus is an infrequent cause of mechanical bowel obstruction. It is caused by transition of a gallstone in the gastrointestinal tract usually through a biliary-enteric fistula, occurring in 1 to 3% of all cases of mechanical bowel obstruction. In patients with a hepaticojejunostomy gallstones can be formed at the proximal side of it and then pass through the lumen. In this cases hepatolithiasis is associated with recurrent anastomotic stricture and cholangitis. Even though abdomen computed tomography (CT) is very informative for diagnosis of gallstone ileus, it is oftenly found during laparotomy performed for unexplained small bowel obstruction. We present the case of a patient who was admitted with a gallstone ileus, in whom the gallstone stone was formed at the hepaticojejunostomy (liver transplant recipient) and entrapped at afferent loop of the Roux-en-Y jejunojejunostomy. Methods: We present the case of a 22yo female. Heretopic reduced liver recipient 20 years ago because of biliary atresia. Admitted 2 years ago with a mild cholangitis, MRCP demonstrated stenosis of hepaticojejunostomy associated with hepatolithiasis. Treatment consisted in percutaneous dilation of bilioenteric anastomosis and progression of litiasis to jejunum. No complications or symptoms were registered during follow up in the next 2 years. Begun with sudden intermittent colicky abdominal pain, nausea, and vomiting. Computed tomography (CT) evidenced small intestine dilation associated with 2 hyperdense structures of about 30 and 40mm as cause of obstruction (figure). Mild intraabdominal fluid, no large intestine dilation, no other pathological findings. Exploratory laparotomy was performed, extensive adhesiolysis, dilation of roux en Y afferent loop, a gallstone of 40mm was the cause of obstruction. A second gallstone was found distally. Enterotomy with gallstone removal was performed. Postoperative occurred without incidents. Patient was discharged at day 3. Results: Intestinal obstruction has many causes, gallstone ileus is infrequent and usually secondary to cholecystoduodenal fistula which is corresponds to an abnormal communication between the gallbladder and the duodenum that occurs as a rare complication of an untreated gallstones. Other cause of gallstone ileus is hepatolihtiasis formed over a pathologic hepaticojejunostomy with anastomotic stricture and recurrent cholangitis. In this cases, the usual complication is a cholangitis secondary to the obstruction and infection of the bile duct. Percutaneous approach consists in stricture dilation and extraction and/or progression of lithiasis, surgery is a more aggressive and morbid approach which consists in hepaticojejunostomy re do. In our patient gallstone ileus was caused by gallstones advanced during percutaneous treatment 2 years before. Clinical and radiological manifestations of small bowel obstruction do not differ. Neither does surgical treatment, in which laparotomy is the most common approach and enterotomy with gallstone extraction is indicated. Conclusion: We present an extremely rare case of gallstone ileus due to hepatolithiasis caused by stricture of hepaticojejunostomy in a liver transplant recipient. Percutaneous treatment was performed to treat bilioenteric stricture, however this procedure progressed lithiasis distally into jejunal loop causing a small bowel obstruction 2 years later.