Adult Female With Abdominal Pain
Article Outline
[Ann Emerg Med. 2012;59:e1-e2.]
An 87-year-old woman presented to the emergency department with abdominal pain, constipation, and vomiting. She had a history of percutaneous cholecystostomy after acute cholecystitis with a large gallstone 6 months before (Figure 1). Her physical examination demonstrated absence of bowel sounds and tympanic abdominal percussion. A computed tomography (CT) scan of the abdomen was obtained (Figure 2).
Figure 1.
Abdominal CT image 6 months before the current presentation, showing a large stone in the gallbladder (arrow) and a percutaneous cholecystostomy catheter.
Figure 2.
Present abdominal CT image demonstrating a large stone within the sigmoid colon (arrow).
Diagnosis
Sigmoid gallstone ileus by cholecystocolic fistula
The current abdominal CT demonstrated the migration of a large gallstone into the colon by a cholecystocolic fistula, blocking the sigmoid colon (Figure 2). Intestinal obstruction by gallstones account for about 1% to 4% of all cases of intestinal obstruction.1 The terminal ileum is the most common location, whereas the colon, with an incidence of 2% to 8%, is a more rare location.2 The arrival of a large gallstone (>2 cm) to the intestine most often occurs as a result of a cholecystenteric fistula, a rare complication of cholelithiasis (about 1% to 3%).3 The most common location of these fistulas is cholecystoduodenal (76%), followed by cholecystocolic (15%).4 Abdominal CT can establish the diagnosis and accelerate the implementation of an effective therapy usually involving surgical enterolithotomy, although, as in this case, endoscopic treatment with fragmentation and stone extraction is possible (Figure 3).
Figure 3.
Endoscopic image of the gallstone located within the sigmoid colon.
Used with permission of José Miguel Rosales Zábal, MD, Emergency Department, Agencia Sanitaria Costa del Sol, Marbella, Málaga, Spain.
References
- . Gallstone ileus: diagnostic pitfalls and therapeutic successes . J Clin Gastroenterol . 2000;30:72–76
- . Colonic gallstone ileus . J Belge Radiol . 1994;77:272–274
- Obstrucción aguda de colon secundaria a litiasis biliar . Rev Esp Digest . 1996;88:805–808
- . Gallstone ileus: diagnosis and management . World J Surg . 2007;31:1292
For the diagnosis and teaching points, see page e2.
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PII: S0196-0644(11)00717-7
doi:10.1016/j.annemergmed.2011.06.018
© 2011 Published by Elsevier Inc.
