Gallstone Ileus: Endoscopic Management

Our patient is a 55 year old woman presenting with intermittent episodes of periumbilical abdominal pain and nausea of 2 months duration.
She had extensive prior history of abdominal surgeries including ovarian cancer resection complicated by colonic perforation. This was treated with segmental colonic resection and temporizing ileostomy. Subsequently ileostomy take down and ileo-ileal anastamosis were performed. Last surgery was approximately 1 year ago.
CT scan of the abdomen on presentation and on repeat scan 1 month later showed a large stone measuring 3 by 2 cm with a characteristic central hypodense core in the distal ileum. In addition a mild dilation of the ileum upto 3.2 cm was noted. There were no stones in a small gallbladder. Of note on a CAT scan done 6 months prior to presentation, similar appearing stone was noted in the gallbladder. Clinical presentation in conjunction with serial CAT scan findings was consistent with intermittent ileus secondary to a large gallstone. Endoscopic management was felt to be less invasive option compared to surgery.
Retrograde double balloon enteroscopy was performed to access the ileum. At approximately 30 cm proximal to the ileo-cecal valve, significant resistance to advancement of the enteroscope was encountered.
The resistance was due to a high grade ileal stricture. This could be an ileo-ileal anastamotic stricture or an inflammatory stricture due to chronically lodged gallstone in the ileum.
The ileal stricture was successfully balloon dilated serially from 12 to 18 mm.
On fluoroscopic views, the waist on the dilating balloon was seen.
which was completely obliterated, indicating successful dilation.
Once double balloon enteroscope successfully traversed the dilated stricture, a large stone was visualized in immediate proximity. The size of the stone was deemed relatively large to be easily extracted through the freshly dilated high grade stricture. Hence stone fragmentation was planned.
Initial attempts at stone fragmentation using electrohydraulic lithotripter at the setting of 80 and total of 876 shocks resulted in only superficial fragmentation. In addition, due to free floating nature of the stone in a dilated ileum, the stone migrated proximally.
Under fluoroscopic guidance, the migrated stone was successfully captured by lithotripsy basket.
As demonstrated here on endoscopic view.
Despite application of maximal mechanical forces by the lithotripter, the stone could not be fragmented. At this juncture lithotripsy wires were partially relaxed and mechanical handle of the lithotripter removed to pass electrohydaulic lithotripter through the enteroscope. Repeat application of electrohydraulic lithotripter was performed on the captured and stabilized stone.
Following this, enteroscope was removed and mechical lithotripter was advanced through the double balloon overtube. Application of further mechanical forces resulted in stone fragmentation.
Stone fragments were successfully extracted across the ileal stricture. Largest of the extracted stone fragments measured 1.8 by 1 cm.
In summary intermittent ileus secondary to a large gallstone and ileal stricture was successfully treated by endoscopy, utilizing retrograde double balloon enteroscopy, stricture balloon dilation and stone fragmentation with electrohydraulic and mechanical lithotriptors. This case demonstrates expanding therapeutic armentarium of deep enteroscopy. Thus yet another surgery was avoided in this patient with prior extensive abdominal surgeries.

Contributed By:
Haritha Avula, MD,