TH7.6 Recurrent Gallstone Ileus: A Case Report

Abstract Introduction Gallstone Ileus (GSI) is a rare cause of mechanical bowel obstruction secondary to impaction of an ectopic gallstone within the bowel lumen. Recurrent GSI is rare, accounting for less than 3% of SBO. The main risk factors for recurrence include a large choleduodenal fistula, an active fistula or faceted gallstones. There is currently no mainstay approach to managing GSI, with “single-stage” and “two-stage” options advocated. Case A 73-year-old lady presented with epigastric pain and vomiting, and was shown to have an obstructing gallstone in the distal ileum. She underwent a laparotomy and enterolithotomy and initially made a good recovery. However, she represented three months later with similar symptoms and was found to have a jejunal gallstone causing proximal small bowel obstruction. She underwent a second enterolithotomy, and is planned for an interval cholecystectomy. Discussion The management of recurrent GSI include one of three options: enterolithotomy alone, “single-stage” (enterolithotomy, cholecystectomy and fistula repair) or “two-stage” approach (enterolithotomy and interval cholecystectomy). The optimal approach in management is still debated. The traditionally taught two-stage approach demonstrates a lower mortality and recurrence rate and shorter index procedure in the unstable patient, requiring a skillset common to most general surgeons. However, with increasing reports of recurrent GSI, a single-stage approach during the index procedure has been advocated, citing decreased risk of cholecystitis, cholangitis and repeat laparotomy in the event of recurrence. Our patient underwent emergency enterolithotomy on both presentations, however there may support for a “single-step” approach in certain patient cohorts.