GIANT GALLSTONE IMPACTION IN STENOSING COLON NEOPLASIA – CASE REPORT

Case Presentation A 72-year-old female patient with a history of hypertension and diabetes, and a previous diagnosis of cholelithiasis, had been awaiting elective surgery for one month. She was admitted with severe right upper quadrant abdominal pain, nausea, and vomiting. She denied any changes in bowel habits, with the last bowel movement occurring one day prior. Physical examination revealed a mildly distended abdomen, tenderness on palpation of the right upper quadrant, and no signs of peritonitis. Imaging (abdominal CT and MRI) showed cholelithiasis with loss of cleavage between the gallbladder and the small bowel, pneumobilia, a gallstone in the cecum, as well as thickening of the transverse colon and distension of the small bowel loops. A laparotomy was indicated due to an intestinal obstruction. During surgery, intense adhesions were found between the gallbladder and the first portion of the duodenum, with a “napkin-ring” lesion in the transverse colon and mild distension of the small bowel loops. A right hemicolectomy with primary anastomosis and resection of the greater omentum was performed, without addressing the cholecystoduodenal fistula during this procedure. Upon opening the specimen, a 3 cm gallstone was found impacted in a stenosing tumor at the splenic flexure of the transverse colon. The patient had an uneventful recovery and was discharged early. The postoperative pathological examination revealed an ulcerated mucin-producing invasive adenocarcinoma, moderately differentiated, infiltrating adjacent adipose tissue, with free surgical margins and involvement of two regional lymph nodes. The staging was T3N1M0, and the patient was referred for adjuvant chemotherapy.

Discussion Biliary ileus is a rare cause of colonic obstruction (2-8% of cases) caused by the impaction of a gallstone in a substenosing segment of the colon, secondary to diverticular disease or pelvic irradiation. Its diagnosis is suggested by the presence of intestinal obstruction, pneumobilia, and ectopic gallstones, the “classic triad,” though it is present in fewer than 50% of cases. Treatment typically involves resolving the intestinal obstruction, with or without correction of the biliary fistula.

Conclusion We describe a rare case of intestinal obstruction due to biliary ileus with a gallstone impacted in a stenosing transverse colon tumor, which was an incidental finding. The diagnosis and treatment of the tumor in this case were only possible due to the acute and unusual obstruction presentation.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025