A 75-year-old woman was admitted to our hospital with a 3-week history of abdominal discomfort, vomiting and diarrhoea. On physical examination a non-generalized abdominal tenderness and distension was encountered.
Laboratory ﬁndings revealed leukocytosis of 19.8 x 10^6/L. There was no deranged liver biochemistry.
An abdominal contrast enhanced CT showed a thick walled, air-ﬁlled gall bladder, a distended stomach and dilated loops of small intestine (Fig.1). Although no gallstone could be identiﬁed, these ﬁndings suggested the presence of a cholecysto-enteric ﬁstula and gallstone ileus. At laparotomy, three obstructive gallstones were removed from the ileum (Fig. 2). The gallbladder showed a thickened wall and pericystic inﬂammation. Considering the critically ill elderly patient, the gallbladder was left in place.
Recovery was initially uneventful. However, two months later the patient presented with general sickness, high fever (39°) and jaundice. The blood tests showed an inﬂammation, elevated liver enzymes and hyperbilirubinemia. The ERCP showed a slightly dilated common bile duct without an obvious obstructive gallstone. An endoprosthesis was placed and the patient showed some recovery. The fever however persisted and the clinical course deteriorated. A subcostal laparotomy was performed ﬁnding a ﬁrm gallbladder with malignant aspect. Various focal lesions were found in the liver of which intra-operative frozen sections conﬁrmed the diagnosis of adenocarcinoma. Palliative treatment was started.
As a result of a trend to early operative management of symptomatic cholecystolithiasis, late complications of long-standing cholecystitis such as gallstone ileus are becoming exceedingly rare. Controversy exists whether initial surgery for gallstone ileus should be a one-stage procedure including stone removal, cholecystectomy and closure of the bilioenteric ﬁstula [1, 2], or should be limited to removal of obstructive stones . Cholecystoduodenal ﬁstula is the most common cause of gallstone ileus . Gallstone ileus due to primary gallbladder carcinoma is even more infrequent. This case elevates the awareness for gallbladder carcinoma as an underlying cause for biliary-enteric ﬁstula and subsequent gallstone ileus in 6% of the cases .
Jeroen Heemskerk (1), Simon W Nienhuijs (2)
Departments of Surgery,
(1) Laurentius Hospital Roermond; (2) Catharina Hospital Eindhoven, The Netherlands.
J Gastrointestin Liver Dis June 2009 Vol.18 No 2, 251-259