Gallstone ileus occurs almost exclusively in the elderly and accounts for 25 % of
mechanical small-bowel obstructions in patients over the age of 65, with a mortality
of 15 % [1]. Surgery has been the treatment of choice, but has a mortality of 12 - 50 % [1]
[2]
[3]
[4]. We report here an instance of successful colonoscopic removal of a gallstone obstructing
the ileocaecal valve.
A 91-year-old nursing-home resident with dementia was admitted as an emergency with
a 1-week history of lethargy, anorexia, constipation and abdominal distension. She
was dehydrated and was assessed as having a Glasgow Coma Scale score of 9/15, which
improved with fluid resuscitation. Her abdomen was distended and tympanic, with obstructive
bowel sounds. There were no palpable masses. She had significant cardiac morbidity,
and laboratory tests showed a leucocytosis and an elevated urea concentration at 11.2
mmol/l. A plain abdominal radiograph revealed grossly distended loops of large and
small bowel. No air was seen in the biliary tree. No obstructing lesion was found
on gastrograffin enema.
She was managed with nasogastric suction and intravenous fluids. Diagnostic colonoscopy
was undertaken and a large gallstone was found to be impacted at the ileocaecal valve
(Figure [1]). This was snared and retrieved using a large Olympus polypectomy snare. No other
pathological abnormality was identified. The patient made a full recovery and was
discharged back to the nursing home.
Figure 1 A gallstone impacted at the ileocaecal valve.
Early surgical intervention is the mainstay of treatment for gallstone ileus, regardless
of the location of the stone [1]. Surgical treatment comprises enterolithotomy, with or without concurrent fistula
repair and cholecystectomy. Both procedures carry significant morbidity and mortality
[1]
[2]
[3]
[4]. In this case, colonoscopy confirmed the site and cause of small-bowel obstruction
and allowed definitive treatment in a patient who was a high surgical risk. Colonoscopic
retrieval may be technically possible, carries small risks compared with surgery,
and requires a shorter period of rehabilitation.
This paper supports the need for a trial of colonoscopic retrieval of a gallstone
impacted at the ileocaecal valve. There is little to be lost from attempting endoscopic
removal and, potentially, much to be gained. It is possible that there is a role for
pre-procedure computed tomographic confirmation of the diagnosis.
Competing interests: Not declared
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