A 65-year-old woman was admitted to hospital complaining of rectal
discomfort that had begun 2 months earlier. Sigmoidoscopy revealed a round
object about the size of a peach pit, which was covered by nonbloody semisolid
stools ([Fig. 1]).
With the woman under mild anesthesia, the object was extracted by
polypectomy snare and identified as a large gallstone of
6 × 4 cm ([Fig. 2]). An
abdominal ultrasound showed pneumobilia ([Fig. 3]). A biliary-enteric fistula was suspected,
although the patient was totally asymptomatic; in particular, the patient had
never complained of symptoms suggestive of acute cholecystitis. After the
gallstone had been extracted from the rectum, the woman underwent gastroscopy
(negative) and colonoscopy, which showed a fistulous orifice near the hepatic
flexure, with no bile discharge ([Fig. 4]). A
one-stage procedure involving cholecystec-tomy and fistula resection was
performed, resulting in an excellent postoperative clinical course.
Fig. 1 Endoscopic image of the
peach pit-like foreign body impacted in the rectum.
Fig. 2 The gallstone which was
extracted from the rectum.
Fig. 3 Ultrasound image showing
pneumobilia.
Fig. 4 Fistulous orifice at the
hepatic flexure of the colon. No bile drainage was noted from the fistulous
orifice.
Cholecystoenteric fistulas (CEFs) are rare entities characterized by
the formation of an abnormal communication between the gallbladder and the
bowel wall, often resulting in the passage of a gallstone [1]. Previous episodes of acute cholecystitis are often
reported. Two main types of CEF have been described: the cholecystoduodenal
fistula and the cholecystocolonic fistula. Most CEFs have an indolent course,
although chronic bile acid-induced diarrhea with malabsorption and weight loss
has been reported. In one-fifth of patients, CEFs are complicated by gallstone
ileus [2]. Impaction of a gallstone in the rectum is
exceptional; until 2000, only three cases had been reported, all associated
with cholecystocolonic fistulas [3]
[4]
[5].
Extraction of impacted stones is difficult. In our case, the
gallstone was removed through the anus by means of a polypectomy snare. The
Dormia basket was not used, to avoid any potential device impaction. When
endoscopic procedures fail, laparotomy becomes necessary.
After gallstone removal, CEFs can be repaired in a one-stage
surgical procedure along with cholecystectomy. However, in elderly patients at
high surgical risk, CEFs may be treated conservatively even if the risk of
recurrent biliary ileus remains elevated.
Endoscopy_UCTN_Code_TTT_1AQ_2AH
