The Double Edged Stone

Abstract

A 70 yo female presented with a 2 day history of nausea and vomiting, and 1 day of severe diarrhea. She denied hematemesis, abdominal pain, melena, fevers, recent travel and sick contacts. She denied medication, tobacco, and etoh use and had no significant family history. Physical exam was pertinent for a Tmax 99.8, she was anicteric, had high pitched bowel sounds, a distended abdomen with minimal epigastric abdominal tenderness without rebound or guarding. The only abnormal lab was a wbc of 14000. Abdominal xrays were consistent with an incomplete SBO and air in the CBD. CT of the abdomen showed evidence of distention in the jejunum and ileum with several air-fluid levels. The gallbladder could not be identified and there was a presence of a 2cm rounded area of increased density located within the dilated ileum. HIDA scan showed non- visualization of the gallbladder. Upper GI series with small bowel follow through was consistent with a SBO. Pt. underwent an exploratory laparotomy which was revealing for a gallstone located in the terminal ileum, a cholecystoduodenal and cholecystocolonic fistula. The impacted gallstone and gallbladder were removed and the cholecystoenteric fistulas (duodenum, transverse colon) were repaired. Gallstone ileus is a rare but well documented complication of gallbladder disease. It is caused by migration of a gallstone through a cholecystoenteric fistula. The clinical symptoms are dependent on the location of the fistula and stone. The majority of these types of fistulae are usually singular and cholecystoduodenal in location. Impaction of the gallstone, which most often is greater than 2cm is generally located in the terminal ileum. The overall incidence of internal biliary fistula is reported as 0.1 to 0.5%. The majority of patients with a cholecystocolonic fistula are elderly and female (6:1). Diarrhea is the most common presenting symptom and the typical clinical features of gallbladder disease are absent. Our patient presented with a mixed picture; including symptoms of small bowel obstruction along with features consistent with a cholecystocolonic fistula. The etiology of the diarrhea in our patient was likely secondary to bile salts. The combination of a SBO due to a cholecystoduodenal fistula along with severe diarrhea secondary to a cholecystocolonic fistula is an extremely rare event and is unreported in the literature.