An 82-year-old Caucasian woman, with a history of hypertension, depression, hypothyroidism, dyslipidemia, carotid endarterectomy and coronary artery disease, presented with a four-day history of nausea, bilious vomiting and epigastric pain radiating to her left scapula. Her home medications included sertraline, atenolol, calcitriol, levothyroxine, tolterodine, omeprazole, aspirin and atorvastatin. She denied smoking, use of alcohol or drug abuse. On examination, she appeared lethargic but not in acute distress. She was afebrile and had a blood pressure of 157/64 mmHg. Examination of her abdomen revealed abdominal distension, epigastric tenderness, tympanic sounds on percussion and decreased bowel sounds. Initial laboratory results were as follows: hemoglobin 11.4 g/dL, white blood cell count 6.2 × 109/L, platelets 115 × 109/L, creatinine 3.2 mg/dL (normal: < 1 mg/dL), blood urea nitrogen 30 mg/dL, amylase 710 U/L (normal: 30 to 110 U/L), lipase 133 U/L (normal: 22 to 51 U/L), albumin 3.1 g/dL, serum alkaline phosphatase 146 U/L (normal: 35 to 100 U/L) with normal levels of alanine transaminase (ALT), aspartate aminotransferase (AST) and total bilirubin.
A CT scan of her abdomen and pelvis with contrast (Figure 1) showed pneumobilia with a choledochoduodenal fistula (common bile duct and second part of her duodenum), significant wall thickening of the second portion of her duodenum and a large 3.6 cm gallstone obstructing her distal duodenum (Figures 2 and 3). Her stomach and proximal duodenum were dilated with decompression of the distal small and large bowel loops. These findings were consistent with gallstone ileus. In addition there was diffuse mesenteric stranding present throughout her abdomen without bowel wall thickening. An upper gastrointestinal (GI) endoscopy showed 1L of bilious fluid in her stomach with an impacted gallstone that could not be extracted with endoscopy (Figure 4). Our patient underwent an open jejunal enterolithotomy for gallstone removal without cholecystectomy. Also, a right hemicolectomy and ileotransverse colonic anastomosis were performed because of an ischemic ascending colon found intraoperatively. Pathology results revealed a gallstone and colonic mucosal ischemic changes. The postoperative course was complicated by a non-ST elevation myocardial infarction, pulmonary edema leading to respiratory failure requiring mechanical ventilation and disseminated intravascular coagulation manifesting as hemoperitoneum. Over the course of her hospital stay, her total bilirubin level increased up to 35 mg/dL with the direct bilirubin level being 19.8 mg/dL. Our patient had an international normalized ratio of 2.6 on postoperative day 22. Her AST and ALT levels were elevated at 203 U/L and 65 U/L, respectively, but her alkaline phosphatase level was normal. An abdominal ultrasonogram did not show any biliary dilatation. Our patient died 22 days after surgery secondary to cardiopulmonary arrest.
