Extraluminal Gallstone Causing Bowel Obstruction

Images in Radiology www.jpgmonline.com Extraluminal gallstone causing bowel obstruction

Sinha R, Verma R*, Tyagi R**

Department of Radiol- 60-year-old woman presented to the Accident and Emergency department of our institute ogy, Leicester Royal A with symptoms of abdominal pain, distension, pyrexia, and malaise. Blood tests revealed a Infirmary, Leicester LE1 raised white cell count. The symptoms had started 48 hours earlier and gradually worsened. The 5WW, UK. *Glenfield patient had not had a bowel motion for the last 3 days. The initial clinical diagnosis was that of Hospital, Groby Road, acute bowel obstruction. The patient did not have any significant medical history although she Leicester LE3 9QP, had had a laparoscopic cholecystectomy 14 years ago. **Leicester Royal Infirmary, Leicester LE1 Plain radiograph of the abdomen, ultrasound examination and multidetector row CT (MDCT) 5WW, UK scan of the abdomen and pelvis were performed. Correspondence: R. Sinha, Discussion E-mail: [email protected] Plain radiograph of the abdomen revealed dilated small bowel loops in the pelvis and right lower Received : 27-06-04 quadrant (RLQ) with a calcific opacity in the right lumbar region [Figure 1]. The ultrasound ex- Review completed : 08-08-04 amination showed a hypoechoic collection in the RLQ [Figure 2]. A presumptive diagnosis of Accepted : 17-08-04 appendicitis with a contained appendicolith was made. The possibility of an inflamed Meckel’s PubMed ID : 16006709 diverticulum with contained enterolith was also considered as a differential diagnosis. J Postgrad Med 2005;51:131-2

MDCT scan of the abdomen and pelvis confirmed the pres- purulent collection around the terminal ileum. The calculus ence of a calcific opacity with associated mesenteric stranding was removed and the collection was drained surgically. On ex- and a small collection [Figure 3]. Reformatted (1 mm) MDCT amination the calculus was found to be of a mixed bilirubinate images in the sagittal and coronal planes showed the inflam- composition. matory mass to be extra-luminal and posterior to the terminal ileum [Figures 4,5]. The appendix was normal and there was Laparoscopic cholecystectomy is now increasingly used for no evidence of any small bowel diverticula. A diagnosis of small treatment of acute cholecystitis due to its low overall compli- bowel obstruction due to an inflamed, dropped gallstone was cation rates as compared to that of the open surgical approach. made. However, two complications occur more frequently with the laparoscopic technique; first, there is an increased incidence At surgery, a calculus with surrounding inflammation was found of bile duct injury, and secondly an increased incidence of gall adherent to the distal terminal ileum. There was also a small bladder perforation with resultant bile leakage and spillage of

Figure 1: Abdominal radiograph showing a dilated small bowel loop in the Figure 2: Sonographic image from the right lower quadrant right lumbar region with a calcific opacity

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Sinha et al: Bowel obstruction, Gallstones, CT

Figure 3: Axial MDCT image showing calculus posterior to the terminal ileum

Figure 5: Sagittal oblique image showing the inflammation located posterior to the collapsed terminal ileum (arrow).

Douglas and the ovary.[2-3] The varying locations of dropped gallstones are due to the employment of pneumoperitoneum and peritoneal irrigation during the surgical procedure. The reported time range for abscess formation due to a spilled gall- stone is between 4 months to 10 years. CT and ultrasound imaging are reliable in the diagnosis of the complications of dropped gallstones.[4-6]

In summary, we report a case of a dropped gallstone, which being in a slightly atypical anatomical location raised the dif- ferential diagnosis of Meckel’s diverticulitis and appendicitis. The multiplanar imaging capability available with MDCT was crucial in reaching the correct diagnosis. We emphasize that the finding of a collection with contained calculus within the abdomen or pelvis should alert radiologists to the possibility Figure 4: Coronal image again showing the inflammation external to the of an inflamed, dropped gallstone even years after surgery. terminal ileum (thin arrow). Thick arrow marks the caecum References

1. Schafer M, Suter C, Klaiber C, Wehrli H, Frie E, Krahenbuhl L. Spilled gall- gallstones. The incidence of gall bladder perforation during stones after laparoscopic cholecystectomy: A relevant technique? A retro- laparoscopic cholecystectomy is estimated at 15-30%. The in- spective analysis of 10174 laparoscopic cholecystectomies. Surg Endosc 1998;12:305-9. cidence of dropped gallstones is estimated at 10-12%. Late 2. Horton M, Florence MG. Unusual abscess patterns following dropped gall- complications of dropped gallstones, such as abscess forma- stones during laparoscopic cholecystectomy. Am J Surg 1998;175:375-9. 3. Frola C, Cannici F, Cantoni S, Tagliafico E, Luminati T. Peritoneal abscess tion are actually quite rare (0.3%) and can occur years after formation as a late complication of gallstones spilled during laparoscopic the procedure.[1] Bilirubinate stones are more likely to cause cholecystectomy. Br J Radiol 1999;72:201-3. 4. Morrin M, Kruskal J, Hochman M, Saldinger P, Kane R. Radiological features infectious complications as they often contain viable bacteria. of complications arising from dropped gallstones in laparoscopic cholecys- tectomy patients. Amer J Roentgenol AJR 2000;174:1441-5. 5. Bennett AA, Gilkeson RC, Haaga JR, Makkar VK, Onders RP. Complications Inflammation and abscess formation usually occurs in the sub- of “dropped” gallstones after laparoscopic cholecystectomy: Technical con- hepatic space or in the retroperitoneum below the subhepatic siderations and imaging findings. Abdom Imaging 2000;25:190-3. space. Unusual locations have also been reported which in- 6. Anagnostopoulos GK, Sakorafas G, Kolettis T, Kotsifopoulos N, Kassaras G. A case of gallstone ileus with an unusual impaction site and spontaneous clude subphrenic space, right thorax, at trocar sites, pouch of evacuation. J Postgrad Med 2004;50:55-6.

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