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Jonathan Tiong
Monash Health, Australia
Posters & Accepted Abstracts: J Hepato Gastroenterol
We describe the case of a 69 year old male who presented with one day of epigastric pain and vomiting. Initial computed tomography scan of the abdomen reported findings suspicious for chronic cholecystitis, secondary cholecystoduodenal fistula and small bowel obstruction. He was administered antibiotics, given a nasogastric tube and kept fasted with a plan for magnetic resonance enterogram (MRE). Given delays in MRE, a gastrograffin follow through study was performed, showing resolving bowel obstruction. As the patient's symptoms resolved, he was discharged with a plan for outpatient MRE. He represented one day later with worsening right upper quadrant pain. Urgent MRE showed gallstone ileus with a 25mm calculus in the ileum. A subsequent exploratory mini laparotomy and enterotomy revealed a 25mm gallstone in the mid-ileum. Magnetic resonance imaging (MRI) is well regarded as the gold standard for detecting radiolucent and isoattenuating stones otherwise missed on X-ray and CT scans. Because it is scarce and time-consuming, it does not often play a role in the acute setting, even in resource rich settings. Nonetheless, if given a high index of suspicion for gallstone ileus, gallstone ileus warrants an expeditious MRE to confirm the diagnosis, as highlighted in our patient. This case was a demonstration of an a difficult diagnosis of a radiolucent gallstone ileus with a series of negative CT and radiograph findings with a rapidly resolving bowel obstruction after GGFT. Clinicians with a high index of suspicion should advocate for inpatient MRE to confirm the diagnosis and be cognisant that resolution of symptoms may not suggest resolution of pathology. While definitive management is contentious, enterolithotomy is safe and highly successful. Follow up for consideration of definitive management is warranted given the risk of recurrence.
Tiong is an unaccredited General Surgery trainee in Melbourne, Australia with a keen interest in upper GI and hepatobiliary diseases.
