Delayed Duodenal Perforation Following Gallstone-Induced Afferent Loop Obstruction Due to a Cholecystoduodenal Fistula: A Case Report

Delayed Duodenal Perforation Following Gallstone-Induced Afferent Loop Obstruction Due to a Cholecystoduodenal Fistula: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Delayed Duodenal Perforation Following Gallstone-Induced Afferent Loop Obstruction Due to a Cholecystoduodenal Fistula: A Case Report Baki Türkoğlu, Mehmet Dinçay Yar, Bilgi Karakaş, Hüseyin Mert Tezcan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7895500/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Gallstone ileus due to a cholecystoduodenal fistula is a rare complication of chronic cholelithiasis, often leading to small bowel obstruction. While ileal obstruction is common, duodenal impaction and its consequences, including afferent loop syndrome, remain underreported. A significant yet often overlooked risk in these cases is delayed duodenal perforation after gallstone removal. Method: We present a 77-year-old female who developed afferent loop syndrome secondary to a gallstone migrating through a cholecystoduodenal fistula 40 years after distal gastrectomy with Billroth II reconstruction. The gallstone lodged in the third portion of the duodenum, causing afferent loop obstruction, bile stasis, and acute pancreatitis. Emergency laparotomy and gallstone removal were performed to restore the afferent loop flow. Result: However, after two days postoperatively, the patient developed duodenal perforation at the previous site of impaction, requiring a second surgery for repair. Conclusion: This case underscores the need for close postoperative monitoring in gallstone-induced duodenal obstructions due to the risk of delayed perforation and highlights the importance of recognizing cholecystoduodenal fistula as an underlying cause of afferent loop syndrome. Novel Aspect: This case emphasizes the possibility of delayed perforation after a gallstone-induced afferent loop syndrome and recommends intense postoperative care for these patients. gallstone ileus afferent loop syndrome cholecystoduodenal fistula delayed perforation case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Gallstone ileus accounts for 1%–4% of all mechanical bowel obstructions, particularly in elderly patients. It occurs due to the formation of a biliary-enteric fistula, most frequently a cholecystoduodenal fistula, allowing gallstones to enter the gastrointestinal tract and cause obstruction [ 1 ]. Afferent loop syndrome (ALS) is another potential complication in patients with a history of Billroth II reconstruction. ALS occurs due to obstruction of the afferent limb, leading to bile stasis, bacterial overgrowth, and acute pancreatitis. While ALS is often attributed to adhesions or anastomotic strictures, in this case, the obstruction resulted from a gallstone migrating via a cholecystoduodenal fistula and lodging in the third portion of the duodenum [ 2 ]. Perforation due to gallstone obstruction is a rare but serious complication, caused by pressure necrosis and localized ischemia [ 3 ]. Case Presentation A 77-year-old female with a history of distal gastrectomy and Billroth II gastrojejunostomy for peptic ulcer disease 30 years ago presented with epigastric pain for 15 days. The pain worsened in last 8 hours. The patient also vomited 2 times after onset of the pain. On physical examination, she was tachycardic (110 beat /per minute) with tenderness and rebound tenderness in the epigastrium and right hypochondrium, Murphy’s sign was positive. Bowel sounds were hypoactive. Laboratory results showed leukocytosis (WBC: 9,950 x10^9 /L), mildly elevated AST: 75 IU/L, ALT was normal, and significantly elevated amylase (348 U/L) and lipase (1920 U/L), consistent with acute pancreatitis. Bilirubin levels were normal, alkaline phosphatase was 214(U/L) and gamma glutamyl transferase was 51 (U/L). CT imaging revealed an obstruction that caused afferent loop dilation and bile stasis in the third portion of the duodenum, between the superior mesenteric artery and the abdominal aorta—an area where SMA syndrome also occurs (Fig. 1 ). A review of the patient’s previous HRCT scans performed for COPD follow-up, revealed that the previously detected 3 cm gallstone had migrated from the gallbladder (Fig. 2 , 3 ). Heterogeneity between gallbladder and duodenum was also noted, suggesting a cholecystoduodenal fistula. First, endoscopic removal of gallstones in the lumen was attempted, which is a rare practice in the literature, but it was not successful [ 4 ]. Then, an emergency laparotomy was performed. During surgery, a gallstone was palpated but could not be moved (Fig. 4 ). The retroperitoneal duodenum was mobilized by Kocher maneuver and release of the Treitz ligament. The stone was milked into the stomach and removed through a gastrotomy incision. (Fig. 5 ) Given the patient's acute condition, the cholecystoduodenal fistula was not repaired immediately. The duodenum was examined for any damage and the surgery was completed by placing a JP drain in the retroduodenal zone. The patient was taken to the ICU after surgery and her condition improved rapidly with resolution of pancreatitis and obstruction. On postoperative day 2, bile and intestinal content began to come from the drain. Also, abdominal examination showed guarding, and CRP was elevated. An emergent laparotomy confirmed a 1 cm perforation in the posterior wall of the third portion of the duodenum. Although narrowing of the lumen was a known risk, the perforation was closed perpendicularly using a gastrointestinal anastomosis stapler, as the afferent loop carries only bile and pancreatic secretions. No postoperative complications were observed, and the patient was discharged on the 9th postoperative day. Discussion Given the complex interplay of gallstone migration, afferent loop obstruction, and the risk of perforation, the management of such cases requires a tailored approach. Gallstone-induced afferent loop syndrome secondary to a cholecystoduodenal fistula is an uncommon but serious condition. The underlying mechanism involves chronic inflammation leading to fistula formation, allowing gallstones to migrate into the duodenum. When gallstones pass in the duodenum, they can most often cause obstruction in the ileocecal valve, but colon or small bowel obstructions have also been identified [ 1 – 5 ]. Much more rarely, gallstones can cause afferent loop syndrome characterized with stasis of biliary secretions, and subsequent complications such as acute pancreatitis by obstructing the afferent loop in patients whose anatomy has changed due to previous surgery. In these cases, it has been reported that gallstones mostly progress to anastomosis and cause obstruction there [ 2 – 6 ]. To our knowledge, only one other case of afferent loop syndrome has been reported to cause obstruction in the middle of the duodenum, like our case [ 7 ]. The management of the fistula in these cases remains complex. Some advocate for early repair of the cholecystoduodenal fistula, but in unstable patients, this is often deferred. The decision to repair the cholecystoduodenal fistula should be carefully considered based on patient stability and surgical risks. A high index of suspicion, particularly in patients with previous Billroth II surgery and gallstone ileus, is necessary to ensure timely intervention and improved outcomes [ 8 ]. There are certainly perforations related to gallstones or enteroliths in the literature, but delayed perforations are more common in contact with foreign objects such as stents [ 9 – 10 ]. Especially, such a perforation that occurred 2 days after the contact was eliminated with surgical intervention, as in our case, is remarkable. Delayed perforation is a life-threatening event caused by pressure necrosis at the impaction site, leading to localized ischemia and eventual perforation. In cases where the gallstone causes prolonged compression of the intestinal wall, surgical teams should maintain high suspicion for delayed perforation, even after apparent clinical improvement. Conclusion This case underscores the importance of early recognition of gallstone-related afferent loop obstruction and the critical need for postoperative vigilance due to the risk of delayed perforation. While immediate removal of the obstructing gallstone is crucial, post-removal complications should not be underestimated. As perforation may not become clinically evident immediately, patients with enteral impaction of gallstones require close monitoring – including drains. Increased awareness of these complications among clinicians will aid in improving patient outcomes and reducing morbidity associated with delayed perforation. Declarations Conflict Of Interest: All authors declare that there is no conflict of interest. Funding Declarations: All authors declare that there is no funding. Consent to Publish : Patient presented in the case report has consented the publication by signing the informed consent form. İnformed consent form that we submitted to related files title includes consent to publish. Ethics and Consent to Participate Declarations: Not applicable. Author Contribution B.T. and M.D.Y. wrote the manuscript text, B.K. and H.M.T. prepared the visual materials and conducted the literature review. All authors reviewed the manuscript. Data Availability Data sharing is not applicable to this article, as no data were generated or analyzed during the study. References Jakubauskas M, Luksaite R, Sileikis A, et al. Gallstone ileus: management and clinical outcomes. Medicina. 2019;55(9):598. 10.3390/medicina55090598 . Roncon Dias A, Lopes RI. Biliary stone causing afferent loop syndrome and pancreatitis. World J Gastroenterol. 2006;12(38):6229–31. Chelednik A, Street M, Biggs J, et al. Enterolith-induced duodenal stump perforation: rare remote complication of surgery for PUD. Trauma Surg Acute Care Open. 2019;4(1):e000360. 10.1136/tsaco-2019-000360 . Kim HJ, Moon JH, Choi HJ, et al. Endoscopic removal of an enterolith causing afferent loop syndrome using electrohydraulic lithotripsy. Dig Endosc. 2010;22(3):220–2. 10.1111/j.1443-1661.2010.00981.x . Gonzalez-Urquijo M, Rodarte-Shade M, Lozano-Balderas G, et al. Cholecystoenteric fistula with and without gallstone ileus: a case series. Hepatobiliary Pancreat Dis Int. 2020;19(1):36–40. 10.1016/j.hbpd.2019.12.004 . Mashayekhi K, Nguyễn C, Kinoshita A, et al. A rare case of afferent limb syndrome due to a biliary stone 8 years after a Whipple, a case report. HPB. 2023;25(Suppl 1):S177–8. Carbognin G, Biasiutti C, El-Khaldi M, et al. Afferent loop syndrome presenting as enterolith after Billroth II subtotal gastrectomy: a case report. Abdom Imaging. 2000;25(2):129–31. 10.1007/s002619910030 . Kostov D, Kostov V. Gallstone ileus due to a cholecystoduodenal fistula. J Clin Pract Res. 2019;41(4):450. 10.14744/etd.2019.54926 . Lee HG, Hwang S, Joo YH, et al. Gallstone ileus inducing obstructive jaundice at the afferent loop of Roux-en-Y hepaticojejunostomy after bile duct cancer surgery: a case report. Korean J Hepatobiliary Pancreat Surg. 2015;19(2):78–81. 10.14701/kjhbps.2015.19.2.78 . Alkhawaldeh IM, Shattarah O, AlSamhori JF, et al. Late small bowel perforation from a migrated double plastic biliary stent: a case report and a review of literature of 85 cases from 2000 to 2022. Clin Case Rep. 2023;11(11):e7425. 10.1002/ccr3.7425 . Additional Declarations No competing interests reported. Supplementary Files CAREchecklistEnglish2013.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Nov, 2025 Reviews received at journal 12 Nov, 2025 Reviews received at journal 12 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviewers invited by journal 02 Nov, 2025 Editor assigned by journal 02 Nov, 2025 Editor invited by journal 02 Nov, 2025 Submission checks completed at journal 30 Oct, 2025 First submitted to journal 30 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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1","display":"","copyAsset":false,"role":"figure","size":91026,"visible":true,"origin":"","legend":"\u003cp\u003eCT image of gallstone ileus. (yellow arrow: dilated afferent loop, blue arrow: gallstone in duodenum)\u003c/p\u003e","description":"","filename":"figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7895500/v1/ff8ad8a77003ebeb9925fea5.jpeg"},{"id":95807113,"identity":"3aa425db-dc6a-497c-9efd-6babca3f93fe","added_by":"auto","created_at":"2025-11-13 08:48:06","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92665,"visible":true,"origin":"","legend":"\u003cp\u003eCT image of 3 cm gallstone in gallbladder which detected on previous scan (blue arrow)\u003c/p\u003e","description":"","filename":"figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7895500/v1/1d30191514790826f5386e16.jpeg"},{"id":95807285,"identity":"e4963de8-fa4e-4445-8f6d-2db56aaabf91","added_by":"auto","created_at":"2025-11-13 08:48:16","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":78568,"visible":true,"origin":"","legend":"\u003cp\u003eCT image of cholecystoduodenal fistula (the arrow points to cholecystoduodenal fistula zone, absence of the gallstone and loss of gallbladder volume)\u003c/p\u003e","description":"","filename":"figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7895500/v1/660952283dd64d444c70ae97.jpeg"},{"id":95807258,"identity":"f099f257-c179-4df0-bc4a-c4b9519d8177","added_by":"auto","created_at":"2025-11-13 08:48:15","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":159774,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative image of gallbladder stone palpated after passing into the stomach\u003c/p\u003e","description":"","filename":"figure4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7895500/v1/1a4a776e35da93a6c812d793.jpeg"},{"id":95807313,"identity":"65bd6658-1ffc-4e77-a06e-ef5d6ac33fe2","added_by":"auto","created_at":"2025-11-13 08:48:19","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":53124,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative image of gallstone extracted via gastrotomy\u003c/p\u003e","description":"","filename":"figure5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7895500/v1/417e9298c72a713edc82cd4b.jpeg"},{"id":95819778,"identity":"0a616ca2-c9ca-45f5-aeb7-99d7bf384d7e","added_by":"auto","created_at":"2025-11-13 10:42:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":878624,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7895500/v1/873b3aa6-a4b8-437a-b009-c9bc3b885965.pdf"},{"id":95807332,"identity":"9952c8c4-a9fb-4b61-a11b-c2f2571d0f04","added_by":"auto","created_at":"2025-11-13 08:48:22","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":729261,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7895500/v1/b0829b7e2fe6752b34a972dc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delayed Duodenal Perforation Following Gallstone-Induced Afferent Loop Obstruction Due to a Cholecystoduodenal Fistula: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGallstone ileus accounts for 1%\u0026ndash;4% of all mechanical bowel obstructions, particularly in elderly patients. It occurs due to the formation of a biliary-enteric fistula, most frequently a cholecystoduodenal fistula, allowing gallstones to enter the gastrointestinal tract and cause obstruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAfferent loop syndrome (ALS) is another potential complication in patients with a history of Billroth II reconstruction. ALS occurs due to obstruction of the afferent limb, leading to bile stasis, bacterial overgrowth, and acute pancreatitis. While ALS is often attributed to adhesions or anastomotic strictures, in this case, the obstruction resulted from a gallstone migrating via a cholecystoduodenal fistula and lodging in the third portion of the duodenum [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Perforation due to gallstone obstruction is a rare but serious complication, caused by pressure necrosis and localized ischemia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 77-year-old female with a history of distal gastrectomy and Billroth II gastrojejunostomy for peptic ulcer disease 30 years ago presented with epigastric pain for 15 days. The pain worsened in last 8 hours. The patient also vomited 2 times after onset of the pain. On physical examination, she was tachycardic (110 beat /per minute) with tenderness and rebound tenderness in the epigastrium and right hypochondrium, Murphy\u0026rsquo;s sign was positive. Bowel sounds were hypoactive. Laboratory results showed leukocytosis (WBC: 9,950 x10^9 /L), mildly elevated AST: 75 IU/L, ALT was normal, and significantly elevated amylase (348 U/L) and lipase (1920 U/L), consistent with acute pancreatitis. Bilirubin levels were normal, alkaline phosphatase was 214(U/L) and gamma glutamyl transferase was 51 (U/L).\u003c/p\u003e\u003cp\u003eCT imaging revealed an obstruction that caused afferent loop dilation and bile stasis in the third portion of the duodenum, between the superior mesenteric artery and the abdominal aorta\u0026mdash;an area where SMA syndrome also occurs (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A review of the patient\u0026rsquo;s previous HRCT scans performed for COPD follow-up, revealed that the previously detected 3 cm gallstone had migrated from the gallbladder (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e,\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Heterogeneity between gallbladder and duodenum was also noted, suggesting a cholecystoduodenal fistula.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFirst, endoscopic removal of gallstones in the lumen was attempted, which is a rare practice in the literature, but it was not successful [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Then, an emergency laparotomy was performed. During surgery, a gallstone was palpated but could not be moved (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The retroperitoneal duodenum was mobilized by Kocher maneuver and release of the Treitz ligament. The stone was milked into the stomach and removed through a gastrotomy incision. (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) Given the patient's acute condition, the cholecystoduodenal fistula was not repaired immediately. The duodenum was examined for any damage and the surgery was completed by placing a JP drain in the retroduodenal zone. The patient was taken to the ICU after surgery and her condition improved rapidly with resolution of pancreatitis and obstruction.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOn postoperative day 2, bile and intestinal content began to come from the drain. Also, abdominal examination showed guarding, and CRP was elevated. An emergent laparotomy confirmed a 1 cm perforation in the posterior wall of the third portion of the duodenum. Although narrowing of the lumen was a known risk, the perforation was closed perpendicularly using a gastrointestinal anastomosis stapler, as the afferent loop carries only bile and pancreatic secretions. No postoperative complications were observed, and the patient was discharged on the 9th postoperative day.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGiven the complex interplay of gallstone migration, afferent loop obstruction, and the risk of perforation, the management of such cases requires a tailored approach. Gallstone-induced afferent loop syndrome secondary to a cholecystoduodenal fistula is an uncommon but serious condition. The underlying mechanism involves chronic inflammation leading to fistula formation, allowing gallstones to migrate into the duodenum. When gallstones pass in the duodenum, they can most often cause obstruction in the ileocecal valve, but colon or small bowel obstructions have also been identified [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Much more rarely, gallstones can cause afferent loop syndrome characterized with stasis of biliary secretions, and subsequent complications such as acute pancreatitis by obstructing the afferent loop in patients whose anatomy has changed due to previous surgery. In these cases, it has been reported that gallstones mostly progress to anastomosis and cause obstruction there [\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To our knowledge, only one other case of afferent loop syndrome has been reported to cause obstruction in the middle of the duodenum, like our case [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe management of the fistula in these cases remains complex. Some advocate for early repair of the cholecystoduodenal fistula, but in unstable patients, this is often deferred. The decision to repair the cholecystoduodenal fistula should be carefully considered based on patient stability and surgical risks. A high index of suspicion, particularly in patients with previous Billroth II surgery and gallstone ileus, is necessary to ensure timely intervention and improved outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere are certainly perforations related to gallstones or enteroliths in the literature, but delayed perforations are more common in contact with foreign objects such as stents [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Especially, such a perforation that occurred 2 days after the contact was eliminated with surgical intervention, as in our case, is remarkable. Delayed perforation is a life-threatening event caused by pressure necrosis at the impaction site, leading to localized ischemia and eventual perforation. In cases where the gallstone causes prolonged compression of the intestinal wall, surgical teams should maintain high suspicion for delayed perforation, even after apparent clinical improvement.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores the importance of early recognition of gallstone-related afferent loop obstruction and the critical need for postoperative vigilance due to the risk of delayed perforation. While immediate removal of the obstructing gallstone is crucial, post-removal complications should not be underestimated. As perforation may not become clinically evident immediately, patients with enteral impaction of gallstones require close monitoring \u0026ndash; including drains. Increased awareness of these complications among clinicians will aid in improving patient outcomes and reducing morbidity associated with delayed perforation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict Of Interest:\u003c/h2\u003e\n\u003cp\u003eAll authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eFunding Declarations:\u003c/h2\u003e\n\u003cp\u003eAll authors declare that there is no funding.\u003c/p\u003e\n\u003ch2\u003eConsent to Publish :\u003c/h2\u003e\n\u003cp\u003ePatient presented in the case report has consented the publication by signing the informed consent form. İnformed consent form that we submitted to related files title includes consent to publish.\u003c/p\u003e\n\u003ch2\u003eEthics and Consent to Participate Declarations:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eB.T. and M.D.Y. wrote the manuscript text, B.K. and H.M.T. prepared the visual materials and conducted the literature review. All authors reviewed the manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData sharing is not applicable to this article, as no data were generated or analyzed during the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJakubauskas M, Luksaite R, Sileikis A, et al. Gallstone ileus: management and clinical outcomes. Medicina. 2019;55(9):598. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/medicina55090598\u003c/span\u003e\u003cspan address=\"10.3390/medicina55090598\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoncon Dias A, Lopes RI. Biliary stone causing afferent loop syndrome and pancreatitis. World J Gastroenterol. 2006;12(38):6229\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChelednik A, Street M, Biggs J, et al. Enterolith-induced duodenal stump perforation: rare remote complication of surgery for PUD. Trauma Surg Acute Care Open. 2019;4(1):e000360. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/tsaco-2019-000360\u003c/span\u003e\u003cspan address=\"10.1136/tsaco-2019-000360\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim HJ, Moon JH, Choi HJ, et al. Endoscopic removal of an enterolith causing afferent loop syndrome using electrohydraulic lithotripsy. Dig Endosc. 2010;22(3):220\u0026ndash;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1443-1661.2010.00981.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1443-1661.2010.00981.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGonzalez-Urquijo M, Rodarte-Shade M, Lozano-Balderas G, et al. Cholecystoenteric fistula with and without gallstone ileus: a case series. 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Korean J Hepatobiliary Pancreat Surg. 2015;19(2):78\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14701/kjhbps.2015.19.2.78\u003c/span\u003e\u003cspan address=\"10.14701/kjhbps.2015.19.2.78\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlkhawaldeh IM, Shattarah O, AlSamhori JF, et al. Late small bowel perforation from a migrated double plastic biliary stent: a case report and a review of literature of 85 cases from 2000 to 2022. Clin Case Rep. 2023;11(11):e7425. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ccr3.7425\u003c/span\u003e\u003cspan address=\"10.1002/ccr3.7425\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"gallstone ileus, afferent loop syndrome, cholecystoduodenal fistula, delayed perforation, case report","lastPublishedDoi":"10.21203/rs.3.rs-7895500/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7895500/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eGallstone ileus due to a cholecystoduodenal fistula is a rare complication of chronic cholelithiasis, often leading to small bowel obstruction. While ileal obstruction is common, duodenal impaction and its consequences, including afferent loop syndrome, remain underreported. A significant yet often overlooked risk in these cases is delayed duodenal perforation after gallstone removal.\u003c/p\u003e\u003ch2\u003eMethod:\u003c/h2\u003e\u003cp\u003eWe present a 77-year-old female who developed afferent loop syndrome secondary to a gallstone migrating through a cholecystoduodenal fistula 40 years after distal gastrectomy with Billroth II reconstruction. The gallstone lodged in the third portion of the duodenum, causing afferent loop obstruction, bile stasis, and acute pancreatitis. Emergency laparotomy and gallstone removal were performed to restore the afferent loop flow.\u003c/p\u003e\u003ch2\u003eResult:\u003c/h2\u003e\u003cp\u003eHowever, after two days postoperatively, the patient developed duodenal perforation at the previous site of impaction, requiring a second surgery for repair.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eThis case underscores the need for close postoperative monitoring in gallstone-induced duodenal obstructions due to the risk of delayed perforation and highlights the importance of recognizing cholecystoduodenal fistula as an underlying cause of afferent loop syndrome.\u003c/p\u003e\u003ch2\u003eNovel Aspect:\u003c/h2\u003e\u003cp\u003eThis case emphasizes the possibility of delayed perforation after a gallstone-induced afferent loop syndrome and recommends intense postoperative care for these patients.\u003c/p\u003e","manuscriptTitle":"Delayed Duodenal Perforation Following Gallstone-Induced Afferent Loop Obstruction Due to a Cholecystoduodenal Fistula: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 08:06:35","doi":"10.21203/rs.3.rs-7895500/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-17T10:45:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T04:05:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-12T21:41:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274149686408125651938083390298198080670","date":"2025-11-04T21:16:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294424225090578560234126901285621509070","date":"2025-11-03T20:32:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-02T20:54:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-02T08:51:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-02T08:21:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-30T13:48:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-10-30T13:46:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ff655f2-8396-459e-8459-8852f3ffc572","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-03T06:38:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-13 08:06:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7895500","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7895500","identity":"rs-7895500","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}