Gallstone ileus developing two months after endoscopic papillary large balloon dilatation: a case report

Gallstone ileus is a rare clinical entity causing bowel obstruction, and transpapillary migration of gallstones after endoscopic retrograde cholangiopancreatography is exceptionally uncommon. Although endoscopic papillary large balloon dilatation is an effective procedure that dilates the Vater's papilla to remove larger size calculi, gallstone ileus following the procedure as a complication has rarely been reported in the literature.

We present the case of an 89-year-old Japanese woman diagnosed with acute cholangitis due to choledocholithiasis, exhibiting epigastric pain, nausea and jaundice. She was treated with endoscopic procedure, including papillary large balloon dilatation, but attempts at stone extraction were unsuccessful. Two months later, the patient was readmitted with acute cholangitis, likely secondary to biliary stent occlusion; however, retrospective review of the computed tomography revealed multiple common bile duct stones as well as a large intrajejunal foreign body consistent with a stone. One day after undergoing urgent endoscopic procedure, she developed recurrent vomiting and was diagnosed with gallstone ileus due to impaction of the stone in the ileum. Following failed endoscopic disimpaction, urgent surgery was performed, and the stone was manually fragmented into several pieces and pushed distally without the need for enterotomy. She was discharged from the hospital on eighth day after the operation.

To our knowledge, this is one of the very few cases of gallstone ileus occurring after endoscopic papillary large balloon dilatation. When extraction of a large common bile duct stone is difficult even after endoscopic papillary large balloon dilatation, additional treatment strategies should be considered, given the potential risk of delayed spontaneous passage and subsequent gallstone ileus.