Gallstone sigmoid obstruction treated with electrohydraulic lithotripsy

Abstract

Figures

Computed tomography. a A 3-cm gallstone (red circle) was seen impacted in the sigmoid colon. b A fistulous communication (arrow) was evident between the gallbladder and colon at the hepatic flexure.

Endoscopic sequence of gallstone treatment with electrohydraulic lithotripsy (EHL). a,b The large, 3-cm gallstone was seen impacted in the sigmoid colon, causing significant ulceration ( a ) and superficial necrosis of underlying mucosa ( b ). c–g A 1.9-Fr EHL probe was passed through the biopsy channel of the gastroscope and EHL was performed to fragment the gallstone. Continuous normal saline irrigation provided a medium for EHL. h,i A Jagwire (Boston Scientific, Marlborough, Massachusetts, USA) was introduced for the placement of a rectal tube.

Full text

Gallstone is a rare cause of large-bowel obstruction. It can result in complete mechanical obstruction in the setting of underlying distal benign or malignant narrowing 1 . Traditionally, surgery is considered the primary treatment modality but carries elevated morbidity and mortality, making nonoperative approaches such as endoscopic mechanical or electrohydraulic lithotripsy (EHL) an integral part of the management 2 .

A 79-year-old woman with a past medical history of uterine cancer and hysterectomy was found to have a large-bowel obstruction, secondary to a 3-cm gallstone impacted in the sigmoid colon from a fistulous communication between the gallbladder and colon at the hepatic flexure ( Fig. 1 ). Initial conservative management failed and the patient was deemed high risk for surgical intervention. Colonic decompression by stone extraction was attempted using conventional tools such as Roth net, snare, and rat-tooth forceps, but these efforts were unsuccessful. After a multidisciplinary discussion, the decision was made to proceed with repeat endoscopic decompression, with attempted fragmentation and removal of the gallstone using EHL.

Computed tomography. a A 3-cm gallstone (red circle) was seen impacted in the sigmoid colon. b A fistulous communication (arrow) was evident between the gallbladder and colon at the hepatic flexure.

Colonoscopy revealed a large impacted pigmented stone in an area of peridiverticular colonic narrowing, causing significant ulceration and superficial necrosis of underlying mucosa. A 1.9-Fr EHL probe was passed through the biopsy channel of the gastroscope, and continuous normal saline irrigation provided a medium for EHL ( Video 1 ). EHL was performed using a Northgate Autolith Touch generator (Northgate Technologies, Inc., Elgin, Illinois, USA), using low power and frequency, which was increased in a stepwise fashion. After successful fragmentation, the scope was advanced beyond the area of obstruction, revealing a dilated colon and no evidence of perforation ( Fig. 2 ). A Jagwire (Boston Scientific, Marlborough, Massachusetts, USA) was introduced for the placement of a rectal tube. Overnight, the patient had multiple bowel movements and was then successfully discharged from the hospital.

Gallstone sigmoid obstruction treated with electrohydraulic lithotripsy.Video 1

Endoscopic sequence of gallstone treatment with electrohydraulic lithotripsy (EHL). a,b The large, 3-cm gallstone was seen impacted in the sigmoid colon, causing significant ulceration ( a ) and superficial necrosis of underlying mucosa ( b ). c–g A 1.9-Fr EHL probe was passed through the biopsy channel of the gastroscope and EHL was performed to fragment the gallstone. Continuous normal saline irrigation provided a medium for EHL. h,i A Jagwire (Boston Scientific, Marlborough, Massachusetts, USA) was introduced for the placement of a rectal tube.

This case highlights the feasibility and safety of endoscopic management of large-bowel obstructions secondary to gallstones using lithotripsy modalities such as EHL, which could be considered a first-line therapeutic option.

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