Dr Helena Blake Dr Nawal Al Khafagi Dr Hossam Mahrous Croydon University Hospital Case synopsis A 78 years old lady presented with abdominal pain vomiting and not passing flatus Examination revealed generalized abdominal tenderness more in the right iliac fossa with gu ID: 933161
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Slide1
Unusual case of gallstone ileus in a patient who underwent cholecystectomy 26 years ago
Dr. Helena Blake Dr. Nawal Al Khafagi Dr. Hossam Mahrous
Croydon University Hospital
Slide2Case synopsis :
A 78 years old lady presented with abdominal pain , vomiting and not passing flatus .Examination revealed generalized abdominal tenderness more in the right iliac fossa with guarding and rebound tenderness. She had no hernias. Her past surgical history was remarkable for cholecystectomy in 1994 and Gastric bypass (Roux-en-Y) in 2016 for weight reduction. She has a past medical history of NASH and autoimmune hepatitis on azathioprine for 10 years and T2DM.Small bowel obstruction was suspected by the abdominal X-rays and routine enhanced CT scan of abdomen and pelvis was done which revealed evidence of small bowel obstruction with mild free fluid and small locules of free gas suggesting perforation of a hallow viscus . A Roux-en-Y gastric bypass noted , the lower esophagus , gastric pouch and adjacent proximal jejunum are normal in caliber. The biliary loop and alimentary loop are massively distended and filled with air and fluid. A peri ampullary diverticulum of the duodenum noted with prominent CBD , no intra biliary gas .The side-to-side jejuno-jejunostomy was widely patent with multiple distended small bowel loops extending down to the pelvis where the lumen was expanded by an apparently intraluminal inhomogeneous mass measuring 4x3x3cm with no contained gas within it, most likely ectopic gall stone without calcification blending in with background bowel content. Beyond this point , the bowel loops are collapsed. The patient underwent laparotomy, and a gall stone was removed from the distal small bowel which was confirmed by histopathology. The patient had un-eventful recovery.
Slide3Gallstone in the terminal ileum
Distended stomach
Ampullary diverticulum
Distended duodenum
Gallstone in the terminal ileum
Collapsed distal loop
Dilated proximal loop
Prominent
CBD
Cholecystectomy clips
Jejuno-Jejunostomy clips
Dilated small bowel loop
Distended
stomach
Free fluid
Free gas
Cholecystectomy clips