![]() ![]() A radiopaque mass was evident within the distal colon (Figure 1). An abdominal X-ray revealed distended loops of bowel concerning for a high-grade small bowel obstruction and pneumoperitoneum. Labs were notable for lactic acidosis at 2.1. However, her abdomen was distended on physical exam and firm with rebound tenderness in the left lower quadrant. Other vital signs were within normal limits, and she appeared in no acute distress. ![]() Upon arrival, she was tachycardic at 120-130 beats per minute (BMP), and her blood pressure was in the 90s systolic. She had no significant past surgical history. She endorsed nausea, vomiting, abdominal distention, and constipation since the onset of her symptoms. The patient is a 51-year-old female with a history of hypertension and atrial fibrillation (on Xarelto) who presented to the emergency department with a one-week history of progressively worsening bilateral lower quadrant abdominal pain. 5 Our case is a rare subset of an already uncommon disease process. A majority of gallstones that enter the gastrointestinal tract become impacted within the ileum (0-89.5%), with less found in the jejunum (0-50%), stomach (0-20%), and the colon (0-8.1%). Pressure necrosis of the gallstone against the biliary wall leads to erosion and fistula formation in the bowel. Pericholecystic inflammation promotes adhesions between the biliary and enteric systems. 8 The pathogenesis of gallstone ileus stems from chronic or recurrent cholecystitis. 8 Women and the elderly are most often affected, with reports as high as 25% in patients over the age of 65 presenting with non-strangulated obstruction. Gallstone ileus is a rare complication of cholelithiasis, occurring in 0.3% of patients with gallstones and comprises 3-4% of benign small bowel obstructions requiring operative intervention. Large bowel obstruction obstruction acute abdomen adhesions colorectal hepatobiliary Furthermore, this case demonstrates the significant impact of diverticular disease on the pathogenesis and management of colonic gallstone ileus. Gallstone ileus is a rare complication of cholelithiasis, and the colon is the most infrequent site of obstruction. The remainder of the patient's hospital course was uncomplicated, and she recovered quite well. The patient was subsequently taken to the intensive care unit in critical condition. Due to the extensive intraabdominal contamination and the patient's hemodynamic instability, the decision was made to leave the cholecystocolonic fistula in place and perform a left hemicolectomy with end colostomy. As a result, an incision was made directly over the gallstone, and it was removed piecemeal. The gallstone was palpated within the upper rectum and fixed within a segment of colonic stricture. In addition, there were perforations at the splenic flexure and sigmoid colon, resulting in gross spillage of stool. The patient was expeditiously taken to the operating room and underwent an exploratory laparotomy which revealed feculent peritonitis and diffuse diverticula with multiple segments of adhesions and strictures along the entire descending colon. CT abdomen/pelvis revealed colonic gallstone ileus with a radiopaque mass at the distal sigmoid colon, inflammation within the hepatic flexure, and air within the gallbladder. Upon arrival, the patient was hypotensive and tachycardic and exhibited significant abdominal distention and diffuse peritonitis on exam. A 51-year-old female presented to the emergency department with one week of progressively worsening abdominal pain, nausea, and vomiting. ![]()
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