Despite gallstone ileus accounts for 25% of non strangulated small bowel obstruction in patients over 65 years of age , colonic gallstone is an uncommon entity. [1] Since Bartolini first described mechanical bowel obstruction secondary to impacted gallstone, different endoscopic options to remove gallstone from the large bowel were attempted. To the best of our knowledge, only one case of colonic gallstone was treated with endoscopic laser lithotripsy. [2] We present a case of 83-year-old lady who presented with sigmoid obstruction secondary to gallstone who was successfully treated with one session of endoscopic laser lithotripsy. This technique allows a safe and conservative management of elderly patients with gallstone impaction at the level of the large bowel.

An 83-year-old-lady was admitted to the hospital with 10 day history of abdominal pain and distension, associated with vomiting and constipation. Three weeks earlier, she was admitted with acute diverticulitis which partially settled with a course of antibiotics but soon thereafter patient gradually became generally unwell, persistently vomiting. Her past medical history included hypertension and gallstones, but she never had abdominal surgery in the past. On examination, the vital signs were stable and the abdomen was distended but non-tender and no palpable masses or hernia was detected. The rectal examination was also normal. Blood tests showed: white blood cells 11,000/mm3 (normal 4000-11000/mm3), hemoglobin 11.9 gm/dL (normal 11.5-16g/dL) but raised urea 13.8 mmol/L (normal 2.5-6.7 mmol/L) and creatinine 174 mcmol/L (70-150mc mol/L). The plain abdominal X-ray revealed small and large bowels obstruction upto the level of distal sigmoid colon but no obvious cause of obstruction was seen. The CECT scan of the abdomen revealed small and large bowels obstruction upto to the level of the sigmoid colon where there was a large laminated calcific density, a gallstone, as the cause of obstruction (Figure 1). There was extensive sigmoid diverticulosis, but no evidence of acute diverticulitis. No malignancy was present. Liver, pancreas and kidneys were normal. No free air or fluid was observed.

Large bowel obstruction due to impacted gallstone is uncommon, and to our knowledge only very few case reports in literature mentioned this rare complication of gallstone disease. Interestingly, in these few case reports, the treatment widely varied from major open surgery (i.e. laparotomy for closure of the cholecysto-colonic fistula and cholecystectomy) which also was done laparoscopically in one case report to less invasive approach like endoscopic removal of the stone if the patient was unfit for such major surgery. The laser lithotripsy for the gallstones in the colon was mentioned only in one case previously. The sigmoid colon is the most common site of obstruction. [3] It occurs mostly in the elderly. A colonic fistula is invariably present between gallbladder and hepatic flexure. [4]

Colonic gallstones may present with non-specific symptoms (diarrhea, electrolyte imbalance), cholangitis or a bleed from the fistula tract. [2] The classical X-ray description of gallstone ileus is Rigler's triad (ectopic gallstone, partial or complete bowel obstruction and gas in biliary tract). [5] Pneumobilia is seen in only a third of cases, probably due to occlusion of the cystic duct from the inflamed gall bladder. [6] [7] [8] CECT scan has proven to be the most effective imaging technique in these cases. [10] [11] Treatment options include enterolithotomy, cholecystectomy and fistula closure as a single operation, [6] [10] [11]or colonoscopic removal of the stone, especially in unfit patients, [6] [12] who can't tolerate a major surgery which carries a mortality risk upto 10-20%. In our case simple removal of the stone by snare or Dormit Basket was not successful, for this case Laser lithotripsy was the best option which helped to remove the stone endoscopically without the need for major surgery.

Colonic gallstones pose a particular diagnostic challenge and demand a high index of suspicion. The classical Rigler's triad on plain abdominal X-ray may not be present and the CECT scan is the ideal imaging study. The treatment is variable, ideally, enterolithotomy, cholecystectomy and fistula closure as a single operation. However, in unfit or elderly patients this operation carries very significant morbidity and mortality. Therefore, using the endoscopic approach (either simple removal of stone by a basket or, if the stone is large, by laser lithotripsy) is the best option and also very safe and effective treatment.

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