Syed Imran Hussain Andrabi  ( Queen Elizabeth Hospital NHS Trust )
Jawad Ahmad  ( Woolwich, London, Department of Surgery, Royal Victoria Hospital )
Muhammad Ahmed  ( Belfast, Ireland, Department surgery, YsbytyGwynedd Hospital )
Muhammad Yousaf  ( Department of Surgery, Belfast City Hospital4, Belfast, Ireland, UK. )

Gallstone ileus is rare following an Endoscopic Retrograde Cholangio-Pancreaticography (ERCP). We present a case where gallstones caused ileus and perforation of small bowel after a therapeutic ERCP.There was no previous history of instrumentation of the papilla or a cholecystoenteric fistula. This case points outa serious morbidity of the rapeutic ERCP for large common bile duct stones.

Mechanical small bowel obstruction due to agallstone, known as gallstone ileus, is a recognized clinical condition and carries a mortality rate of 15-20%.1 Halter etal reported the first case of gallstone ileus following endoscopic retrograde cholangio pancreaticography(ERCP) in 1981.2It is a rare clinical entity and accounts for1-3% of mechanical ileus of the small bowel, but for 25%of all small bowel obstructions in patients older than 65years.3 Usual presentation of the patient is of intestinal obstruction as the gallstone migrates to small intestine following a cholecystoduodenal fistula. However gallstoneileus and perforation of small bowel causing peritonitis isless likely due to passage of stones through common bileduct (CBD), either spontaneously or after therapeutic ERCP. After an exhaustive literature search we found only one similar case reported in 1992 where a patient underwent multiple therapeutic ERCPs and suffered from gallstone ileus and bowel perforation.3ERCP is associated with a 3% incidence of morbidity and 0.2% mortality.4 This case highlights the need for a raisedindex of suspicion of gallstone ileus in patients treated forlarge CBD stones with therapeutic ERCP who present with aclinical picture of bowel obstruction and bowel perforation.

An 84 years old female patient was admitted through accident and emergency with a clinical diagnosis of acute abdomen and sepsis. Blood tests showed a raised white cellcount, C-reactive protein, and deranged liver function tests.Plain abdominal radiograph showed aerobilia and stigmata of sma   ll bowel obstruction. ACT scan was arranged that showed a distended gall bladder with a large gallstone and dilated intra hepatic billiary channels containing air. The small bowel was distended with abrupt change in caliber atthe level of distal ileum possibly due to an isodense calculus causing the obstruction (Figure 1).Prior to this admission, the patient had an ultrasoundscan that showed a distended gall bladder containing a largestone measuring 3.1 x 2.2 x 2.1 cm. The CBD was dilated to2.6 cm containing multiple stones; the largest being 13 mmin diameter. The patient then under went a therapeutic ERCP and endoscopic sphincterotomy (ES) and two large pigment stones were removed from the CBD (Figure 2). Two week safter this procedure, she presented to us with acuteperitonitis. After considering all available data diagnosis of gallstone ileus following the ERCP was made.Exploratory laparotomy showed no evidence of acholycystoenteric fistula. There was proximal small bowel distension with two perforations in the ileum two feet proximal to ileocaecal junction and interestingly, two largestones which had eroded the bowel wall were retrieved.Resection and primary anastomosis was performed with alinear stapler device followed by a cholecystectomy. The histology confirmed small bowel perforation and chroniccholecystitis

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ERCP was first described in 1971.3It is has become agold standard for therapeutic intervention in the management of choledocholithiasis in elderly and high risk patients.5,6I thas a reported success rate of 80-90% with a 6.5-8.7%complication rate.7 Complications of ERCP includehaemorrhage, cholangitis, acute pancreatitis and perforation of hepatobilliary tree or duodenum. Gallstone ileus is a rare complication of ERCPand ES.2Usual presentation of gallstone ileus with perforation is early with usual site of perforation in either cystic duct or common bile duct mainly due to instrumentation and choledochoenteric fistula. It carriesa mortality rate of 15-20%.1 However gallstone ileus alonemay not manifest itself even several days after the procedure.8 Patients with large CBD stones may require extensive sphincterotomies to retrieve the stones as spontaneous passage would be unlikely. Stones of 1.5 cm have been observed topass through without complications.2,7In this case the stones extracted from the terminal ileum at laparotomy were two innumber, noted earlier at ERCP, which confirmed that they must have reached there after the ERCP. Review of earlier reported cases shows that common site of obstruction causingileus was about 50 cm from ligament of Treitz or the obstruction was precipitated by intestinal narrowing either due to adhesions or radiation enteritis.9 In this case we found two large gallstones eroding through the terminal ileum two feetproximal to the ileocaecal valve.Timing of presentation of patient with obstruction is variable. Our patient presented 14 days following ERCP and ES. Usually these patients present early and other author shave reported the delay ranging from 24 hours to two month between ES and obstruction.6 This case reminds that a therapeutic ERCP for CBD stones can cause this rare clinical condition and if a patient presents with signs of intestinal obstruction or peritonitis,gallstone ileus should be considered in the differentialdiagnosis. An early intervention and management is mandatory to prevent mortality10which unfortunately occurred in this case.

Gallstone ileus and perforation of the small bowel isa rare complication of therapeutic ERCP. Efforts should be made to retrieve or shatter the stones in the CBD or bowel during the procedure to prevent this potential fatal complication.

 1.Way LW, Sleisenger MH. Cholelithiasis: chronic and acute cholecystitis. InSleisenger MH, Fordtran JS. Eds. Gastrointestinal disease, ed 4. Philadelphia:W.B.Saunders, 1989: pp 1691-714.

2.Szanto I, Banai J, Szeleczky M, Bozalyi I. Gallstone ileus after endoscopicsphincterotomy. Orv Hetil. 1992; 133:363-5
.3.Despland M, Clavien PA, Mentha G, Rohner A. Gallstone ileus and bowelperforation after endoscopic sphincterotomy. Am J Gastroenterol 1992;87:886-8.

4.Geene JE and Venu RP, "Endoscopic Retrograde Cholangiopancreatography",Bockus Gastroenterology, 4th ed, Chapter 44, Berk JE, ED, Philadelphia, PA:WB Saunders Co, 1985, pp 601-11.

5.Cotton PB, Vallon AG. British experience with duodenoscopic sphincterotomyfor removal of bile duct stones. Br J Surg 1981; 68:373-5.

6.Classen M. Endoscopic papillotomy-- new indications, short- and long-termresults. Clin Gastroenterol 1986;15:457-69.

7.Tondelli P, Gyr K. Biliary tract disorders. Postsurgical syndromes. ClinGastroenterol 1983;12:231-54.

8.Williams IM, Hughes OD, Hicks E, Lewis MH. Gall stone ileus followingmultiple endoscopic retrograde cholangiopancreatographies.. J R Coll SurgEdinb. 1997;42:423.

9.Prackup GM, Babarjee B, Piorkowski RJ, Rosson RS. Gallstone ileusfollowing endoscopic sphincterotomy. J Clin Gastroenterol. 1990;12:230-2.

10.Lancaster JF, Strong RW, McIntyre A, Kerlin P. Gallstone ileus complicatingendoscopic sphincterotomy: Aust N Z J Surg. 1993;63:416-7.