Gallstone Ileus in the setting of Situs Inversus

Heidi J Miller, MD, MPH, Nadia Awad, MD, Jihan Hegazy, MD, FACS. Albert Einstein Healthcare Network.

We present the case of a 42 year old male who presented to the emergency room with 2 days of nausea, vomiting and abdominal pain. He complained of sharp, epigastric pain that radiated to the umbilicus and was associated with distention and watery diarrhea. The patient described previous episodes of LUQ pain associated with spicy food but no similar previous episodes. Past history was reported as hyperlipidemia and an episode of inflammation of the appendix. There was no past surgical history. On exam the patient was tachycardic and hypertensive, in no distress with a soft, distended and tympanic abdomen. Laboratory values were unremarkable except for a mild leukocytosis and elevated creatinine. He had CT scan showing Situs Inversus Totalis and pneuombilia with an impacted gallstone causing a distal small bowel obstruction. He was resuscitated and taken to for exploratory laparotomy with enterolithotomy. A 4x2x2.5cm stone was removed from the distal ileum and the enterotomy was closed with a stapled side-to-side closure. An appendectomy was also completed given the patient’s abnormal location to avoid any further diagnostic confusion. The patient progressed normally postoperatively and was discharged home with outpatient follow up for possible cholecystectomy at a later time.

Gallstone ileus is a rare cause of mechanical small bowel obstruction, usually presenting in elderly women. It occurs in 0.5% of cases of cholelithiasis due to stones greater than 2.5 cm in diameter that pass through a cholecystoenteric fistula. Situs Inversus Totalis is the complete reversal of thoracoabdominal organs that can be associated with biliary anomolies. There are many case reports of successful open and laparoscopic cholecystectomy for acute cholecystitis and symptomatic cholelithiasis in patients with Situs Inversus. However gallstone ileus in a patient with situs inversus has never before been reported.

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