Hospital: Hospital Universitario Ramón y Cajal.
Nº: C2019-236
Aut@r o Autores: J. Quintana Pérez, A. López-Frías López-Jurado, J. Vidal Mondéjar, C. Suevos Ballesteros, L. González Campo, A. Vicente Bártulos.
Presentación
An 85 year-old male presented to the Emergency Department complaining with right upper quadrant pain, nausea, abdominal distension and no deposition for 24 hours. Leucocytosis and elevated cholestasis and cytolysis markers were detected. These findings raised clinical suspicion of acute cholecystitis. An emergent abdominal sonography was performed. A thick-walled but non-distended gallbladder associated with a positive echographic Murphy sign and pericholecystic inflammatory changes were identified. Echogenic material consistent with sludge was detected inside the gallbladder. Dilated small bowel loops and an echogenic focus with posterior acoustic shadowing seemingly located within one of these loops were noted. An emergent contrast-enhanced CT scan was performed to better characterise these findings. Jejunum, duodenum and stomach dilation with a transition point in jejunum in keeping with a 27 mm impacted stone, pneumobilia and a cholecystoduodenal fistula were evinced at CT. Gallbladder wall thickening and pericholecystic inflammatory changes were confirmed.
Discusión
The aforementioned radiological findings were consistent with gallstone ileus. This is an uncommon cause for bowel obstruction (up to 3% of bowel obstruction cases). It usually occurs in the setting of subacute or chronic cholecystitis, in which an impacted gallstone progressively erodes the gallbladder wall and so creates a cholecystoenteric fistula. The gallstone exits the gallbladder through the fistula and impacts in a small bowel loop. Gallstones should measure at least 2.5 cm in diameter to be liable to impact, most frequently in the terminal ileum or jejunum (approximately 75% and 25% of cases respectively). Suggestive radiological findings include: