A case of gallstone-induced small bowel necrosis masquerading as clinical appendicitis |
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Authors: | Siong-Seng Liau Andrew Bamber Malcolm MacFarlane Justin Alberts |
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Institution: | (1) Department of Surgery, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, UK;(2) Department of Surgery, West Suffolk Hospital, Bury St Edmunds, UK;(3) Department of Radiology, West Suffolk Hospital, Bury St Edmunds, UK |
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Abstract: | Cholecysto-duodenal fistula and gallstone ileus are well-recognised complications of gallstone disease. However, small bowel
necrosis is a rare complication of gallstone disease. We describe a case of gallstone-induced ileal necrosis presenting with
symptoms and signs resembling acute appendicitis. A 79-year-old woman presented to the surgical team with central abdominal
pain which subsequently shifted to the right iliac fossa. Clinically, the patient had localised perotinism in the right iliac
fossa with high inflammatory markers. Abdominal radiography showed no diagnostic features. Initial clinical impression was
that of acute appendicitis. Given that this diagnosis was unlikely in a patient of this age, an abdominal CT scan was performed.
The CT scan showed evidence of a large gallstone causing small bowel obstruction in the presence of a cholecysto-duodenal
fistula. At surgery, she was found to have an area of necrosis with a pin-point perforation at the site of impaction of the
gallstone in the proximal ileum. This occurred secondarily to pressure necrosis from the gallstone impacting at a site where
the small bowel diameter narrows in transition from jejunum to ileum. A limited small bowel resection was performed with an
uncomplicated postoperative course. This case report draws attention to a rare complication of gallstone disease which presents
with a clinical picture similar to acute appendicitis. Preoperative investigation for an elderly patient who presents with
an acute abdomen should include an abdominal CT scan to diagnose any rare disease processes which otherwise may not be suspected. |
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Keywords: | Gallstone ileus Small bowel necrosis Appendicitis Surgery |
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