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Description
A woman in her 70s previously diagnosed with gallstones was admitted to the hospital with myocardial infarction. There was ST-segment elevation on her ECG. She underwent acute percutaneous coronary intervention with the placement of a drug-eluting stent in her right coronary artery and subsequently lifelong anticoagulant therapy. After admittance, she had increasing abdominal pain and had no bowel function for 4 days. A CT scan showed a gallbladder with a thickened wall and a fistula to the right colic flexure with incomplete large bowel obstruction due to a gallstone of approximately 5×4.5×3 cm in the sigmoid colon (figure 1). The gallstone was located in the gall bladder 1 year earlier (figure 2).
CT scan of the abdominal from admission, showing the gallstone in the sigmoid colon (arrow).
CT scan of the abdominal from 1 year earlier, showing the gallstone in the gallbladder (arrow).
Bowel obstruction caused by gallstones is a rare complication to cholecystolithiasis. When occurring, the most common location of the obstruction is the terminal ileum (60%–85%). In only 4% of patients with gallstone ileus, the obstruction is in the sigmoid part of the colon.1 The probability of this is increased in the presence of diverticular disease.2
We present a case where we used endoscopic electrohydraulic lithotripsy (EHL) as a first-line strategy. EHL is a minimally invasive technique to fragment stones using a high-voltage electric spark between two isolated electrodes through a liquid. EHL works by creating a hydraulic shock wave that can generate pressure, fragmenting solid objects in its path.3
Under mild sedation, the stone was broken down and removed during a 2-hour EHL session. During the subsequent inspection of the large bowel, multiple diverticula and a fibrotic sigmoid colon were found. See video.(video 1)
The patient had recovered and could be discharged after 2 days. At 3-month follow-up, the patient had normal bowel function and symptoms expectable in a patient with diverticulosis.
EHL is an effective treatment for gallstones in the bowel.2 4 This case presents an effective and successful treatment of sigmoid gallstone ileus in a high-risk patient using EHL. In stable patients suffering from large bowel obstruction caused by gallstones, transfer to hospitals where EHL can be performed should be considered.
Learning points
Bowel obstruction caused by gallstones is a rare condition, and even rarer when located in the sigmoid colon.
In selected patients, endoscopic electrohydraulic lithotripsy (EHL) and endoscopic stone removal may be considered for relief of bowel obstruction secondary to gallstone in the sigmoid colon. EHL is especially relevant in patients with contraindications to surgery, like a newly placed drug-eluting stent requiring anticoagulant therapy.
Ethics statements
Patient consent for publication
Footnotes
Contributors AB contributed in the drafting, editing and revision of the case report. FB contributed in the editing and revision of the case report. MB contributed to the editing, revision and submission of the case report. MB treated the patient.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.