Spontaneous Resolution of Gallstone Ileus with Giant Stone: A Case Report and Literature Review.

Abstract

To the Editor: Bowel obstruction is a frequent clinical condition, in particular in elderly adults, that has nonspecific intermittent symptoms. Gallstone ileus is a rare form of mechanical bowel obstruction due to biliary calculus stuck in the intestinal lumen due to a cholecystoduodenal fistula (68%) but also a cholecystocolonic, cholecystogastric, or left hepatic duct fistula.1 Surgery is the treatment of choice, because spontaneous evacuation is uncommon, especially when the gallstone's diameter is greater than 2.5 cm.2 We report a case of an elderly woman with spontaneous resolution of gallstone ileus secondary to giant stone and provide a mini review of the available literature. An 83-year-old woman, complaining of epigastric pain, biliary vomit, and distension of abdomen for 5 days, was admitted. Her medical history included hypertension, coronary heart disease, carotid artery atherosclerosis, and cholelithiasis, with a recent episode of biliary colic 1 month before admission. Home medications included antiplatelet drugs, thiazides, and nonsteroidal anti-inflammatory drugs. Physical examination did not show any cardiac, pulmonary, or abdominal abnormalities, but she reported light pain during deep palpation on the right side of the abdomen; peristalsis was present. Routine laboratory tests revealed C-reactive protein of 4.7 mg/dL (normal < 0.5 mg/dL), serum creatinine 1.45 mg/dL, low serum sodium (132 mmol/L) and potassium (3.2 mmol/L) levels, and serum high gamma-glutamyl transpeptidase (γGT 207 U/L, normal 8–61 U/L) and alkaline phosphatase (402 U/L, normal 35–105 U/L). Abdominal X-rays showed only fecal impaction, with no bowel air-fluid levels or abdominal free air. A nasogastric tube was inserted, and conservative treatment with broad-spectrum antibiotics and fluid integration was started. Hepatic ultrasonography showed a chronic cholelithiasis without dilatation of biliary tract, but computed tomography (CT) revealed a gallbladder full of air bubbles and a cholecystocolonic fistula, further confirmed by cholangio-magnetic resonance imaging. Thus, although the diagnosis of occlusion caused by migration of one or more biliary calculi into the bowel was made, a surgical approach was excluded because of comorbidities. Medical therapy with methylprednisolone and trimebutine was prescribed. Her general condition gradually improved, and 7 days later, she spontaneously evacuated many calculi, the biggest measuring approximately 5 × 2 cm (Figure 1). Twenty days after admission, she was discharged with no abdominal symptoms and normalization of laboratory tests. Gallstone ileus is an uncommon cause of occlusion of the small bowel, first reported by Rigler and colleagues,3 occurring more often in elderly adults, and characterized by high in-hospital mortality.4 Cholelithiasis is more frequent in elderly adults with diabetes mellitus, current alcohol drinking, and hepatitis B and C infections,5 but only 0.3% to 1.5% of these evolve into a gallstone ileus. Women aged 65 and older are frequently diagnosed and account for more than 25% of all cases of nonstrangulated small bowel.4 Gallstones usually enter the small intestine through a fistula,1 and this abnormal connection between gallbladder, biliary tract, and bowel may induce pneumobilia (34% of cases), intestinal obstruction (70%), and aberrantly located gallstone (35%). Because of their sensitivity, specificity, and diagnostic accuracy, ultrasound and CT should be performed to diagnose gallstone ileus.6 Gallstone ileus usually requires emergency surgery to relieve the intestinal obstruction, but age and comorbidity may suggest a delay surgery in consideration of high mortality (12–18%).7 Spontaneous gallstone evacuation in individuals with mechanical ileus is uncommon, in particular when the gallstone is more than 2.5 cm in diameter, because the terminal ileus and the ileocecal valve, more-frequent locations of bowel obstruction, are narrow and have inefficient peristalsis.2 A review of literature revealed only 10 cases with spontaneous resolution of mechanical ileus (Table 1). These individuals were more likely to be female (n = 6) and had a mean age of 70.6 ± 9.4. In this population, cholecystoduodenal fistula was the principal gateway of stones into the intestine (60% of cases), and in 60% of cases, the gallstone diameter was greater than 2.5 cm (the largest was 6 × 4 cm).8 In elderly adults, internal medicine or geriatric units could be an adequate setting, because a conservative medical approach is generally preferred because of the likelihood of concurrent comorbidities. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: De Giorgi: original idea, acquisition of subject's data, patient care, literature search, preparation of manuscript. Caranti, Moro: acquisition of subject's data, literature search, preparation of manuscript. Parisi, Molino: acquisition of subject's data, patient care, draft review. Fabbian, Manfredini: original idea, acquisition of subject's data, literature search, preparation of manuscript, revision for important intellectual content, final supervision. Sponsor's Role: None.