S3250 From Schatzki's Ring to Small Bowel Obstruction: An Unexpected Case of Gallstone Ileus

Introduction: Our case highlights an unusual presentation of dysphagia that was initially suspected to be caused by a Schatzki's ring but was ultimately diagnosed as a small bowel obstruction due to gallstone ileus. Case Description/Methods: A 73-year-old woman with a history of dysphagia from a known Schatzki's ring presented with severe nausea and vomiting that lasted for 4 days. Due to concerns about recurrent dysphagia, an urgent esophagogastroduodenoscopy (EGD) was performed. The EGD revealed a small sliding hiatal hernia and a partially obstructive Schatzki's ring. The endoscope was advanced into the stomach, where a large amount of retained food, approximately 1.5 liters of fluid, was found and promptly suctioned. Further advancement into the second portion of the duodenum revealed a large, round, firm object suggestive of either a bezoar or a gallstone, which appeared to be causing duodenal obstruction and resulting in upstream dilation and fluid collection. Multiple attempts using grasping forceps and a snare to manipulate or fragment the object were unsuccessful due to its hardness. Unfortunately, peristalsis distanced the object, moving beyond the scope's reach. The procedure was terminated, and an emergent computed tomography scan was performed that revealed a 4.1 cm calcified gallstone that had passed from the gallbladder into the duodenum and was located in a loop of the small bowel, likely the mid- to distal jejunum. The computed tomography also showed several foci of gas within the gallbladder lumen, confirming the presence of a cholecystoenteric fistula. Due to the size of the gallstone, the patient was at risk for gallstone ileus or obstruction at the ileocecal valve. The surgical team was consulted, and a transverse enterotomy was performed to remove the gallstone. After the surgery, the patient was placed on a nasogastric (NG) tube, which was removed once she was able to pass gas and have bowel movements. On the day of her discharge, she tolerated a regular diet without experiencing any abdominal pain or nausea. Discussion: Our case highlights the importance of considering a broad differential diagnosis in elderly patients with gastrointestinal symptoms. Although based on patient medical history, there was an initial suspicion of esophageal disorder, further investigation revealed that a large gallstone was causing a small bowel obstruction due to a cholecystoenteric fistula. Timely identification and surgical intervention resulted in a positive outcome, highlighting the value of early endoscopic evaluation in complex cases.