Presentation
Patient presents to the emergency department with 24 hours of vomiting and abdominal pain.
Patient Data
The are multiple loops of dilated small bowel with small bowel feacalisation of the mid-small bowel. There is a large round laminated object located within the small bowel measuring 26 X 32 mm within the pelvis. It is likely to represent a low-density biliary calculus causing proximal obstruction with collapse of distal bowel loops. This is likely an underlying cholecystoduodenal fistula present.
There intrahepatic and extrahepatic bile duct dilation with no pancreatic head lesion or choledocholithiasis identified. There is a large gall bladder calculus measuring 23 mm in diameter. There is no evidence of gallbladder distension or signs of acute cholecystitis. There is sigmoid diverticulosis.
Case Discussion
This patient was diagnosed as having gallstone ileus, an uncommon cause of small bowel obstruction.
They were managed with an emergency laparotomy, at which time a small enterotomy was performed to remove the obstructing stone and relieve the obstruction. During the surgery, a fistula between the gallbladder and duodenum was demonstrated.
Cholecystoenteric fistulas do not always require surgical management. However, the presence of the large stone, in this case, posed a risk of future obstruction for this patient. In addition to this, there is an increased risk of gallbladder cancer in these patients. The decision was made to perform an elective cholecystectomy and omental patch repair of the duodenal defect.
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