Management of gallstone ileus

Gallstone ileus: report of two cases and a mini literature review

Gallstone ileus is a relatively rare complication of cholelithiasis, and an uncommon cause of small bowel obstruction most commonly seen in elderly and debilitated people with associated comorbidities. Symptoms of gallstone ileus are insidious and may be vague while the delay in diagnosis results in a high mortality rate. Herein we report two cases of gallstone ileus in elderly patients with complex medical history who presented at the emergency department with abdominal pain and distension, vomiting and fluid/electrolyte disorders due to cholecysto-enteric fistula and bowel obstruction.

Bouveret syndrome: two approaches one stone

Bouveret syndrome is a rare cause of gastric outlet obstruction, a consequence of a large impacted gallstone leading to the formation of a bilioenteric fistula. We present a case of a 79-year-old female who presented with a history of persistent nausea and vomiting. Computed tomography of the abdomen revealed a large gallstone impacted in the second part of the duodenum, complicated by a cholecystoduodenal fistula, leading to gastric outlet obstruction. After nasogastric decompression, the patient underwent an upper gastrointestinal endoscopy and attempted stone retrieval which was unsuccessful. Consequently, she underwent laparotomy, gastrotomy, and extraction of the stone. This case highlights the pitfalls of managing Bouveret syndrome via an endoscopic or an open surgical approach.

Colonic gallstone ileus: a systematic literature review with a diagnostic-therapeutic algorithm

Rare complication of gallstone disease is gallstone ileus. The common location is the small intestine, followed by the stomach. The rarest location is colonic gallstone ileus (CGI). To summarize and define the most appropriate diagnostic methods and therapeutic options for CGI based on the paucity of published data. Literature searches of English-, German-, Spanish-, Italian-, Japanese-, Dutch- and Portuguese language articles included and Italian-language articles using PubMed, EMBASE, Web of Science, The Cochrane Library, and Google Scholar. Additional studies were identified from the references of retrieved studies. 113 cases of CGI were recorded with a male to female patient ratio of 1:2.9. The average patient age was 77.7 years (range 45-95 years). The usual location of stone impaction was the sigmoid colon (85.8%), followed by a descending colon (6.6%), transverse colon (4.7%), rectum (1.9%), and lastly, ascending colon (0.9%). Gallstones ranged from 2 to 10 cm. The duration of symptoms was variable (1 day to 2 months), with commonly reported abdominal distension, obstipation, and vomiting; 85.2% of patients had previous biliary symptoms. Diverticular disease was present in 81.8% of patients. During the last 23 years, CT scan was the most common imaging method (91.5%), confirming the ectopic gallstone in 86.7% of cases, pneumobilia in 65.3%, and cholecytocolonic fistula in 68%. The treatment option included laparotomy with cololithotomy and primary closure (24.7%), laparotomy and cololithotomy with diverting stoma (14.2%), colonic resection with anastomosis (7.9%), colonic resection with a colostomy (12.4%), laparoscopy with cololithotomy with primary closure (2.6%), laparoscopy with cololithotomy with a colostomy (0.9%), colostomy without gallstone extraction (5.3%), endoscopic mechanical lithotripsy (success rate 41.1%), extracorporeal shock wave lithotripsy (1.8%). The cholecystectomy rate was 46.7%; during the initial procedure 25%, and as a separate procedure, 21.7%; 53.3% of patients had no cholecystectomy. The survival rate was 87%. CGI is the rarest presentation of gallstone ileus, mainly in women over 70 years of age, with gallstones over 2 cm, and predominantly in the sigmoid colon. Abdominal CT is diagnostic. Nonoperative treatment, particularly in subacute presentations, should be the first-line treatment. Laparotomy with cololithotomy or colonic resection is a standard procedure with favorable outcomes. There are no robust data on whether primary or delayed cholecystectomy is mandatory as a part of CGI management.

Bowel obstruction secondary to gallstone ileus within a strangulated inguinal hernia: Report of a rare diagnosis

INTRODUCTION

Gallstone ileus is rare and inguinal hernias are common causes of intestinal obstruction but combination of them is a very rare cause of intestinal obstruction. It is accepted that in patients with severe comorbidities surgeons can manage inguinal hernias and gallstone conservatively. In this article we report a patient with gallstone and inguinal hernia that managed with conservatively management because of heart failure but admitted with complication of gallstone and hernia and treated successfully.

CASE PRESENTATION

An 80-year-old woman with a history of heart failure and two bouts of acute cholecystitis, who presented with pain and swelling in the inguinal region and obstructive symptoms. And due to the urgent nature of the condition, she underwent surgery.

CONCLUSION

One of the rare complications of gallstones is cholecystoduodenal fistulas, especially in patients whose episodes of cholecystitis are treated medically. Early diagnosis and appropriate surgical management in these circumstances reduce the mortality and morbidity.

Bouveret syndrome masquerading as a gastric mass-unmasked with endoscopic luminal laser lithotripsy: A case report

BACKGROUND

Bouveret syndrome, also known as gallstone ileus, is a rare form of gastric outlet obstruction accounting for 1%-3% of cases. This condition is most often reported in females. The diagnosis can be challenging and is often missed due to atypical presentations, which occasionally mimic gastric outlet obstruction symptoms such as nausea, vomiting, loss of appetite and hematemesis. The symptoms vary with stone size. Larger stones are managed with a surgical approach, but this carries increased morbidity and mortality. Over the past decade, the endoscopic approach has emerged as an alternative mode of treatment, but it is generally unsuccessful in the management of larger-sized stones. A literature review revealed cases of successful endoscopic treatment requiring multiple sessions for stone sizes measuring up to about 4.5 cm. Here we present a unique case of an elderly patient with Bouveret syndrome with a 5 cm stone mimicking a gastric mass and causing gastric outlet obstruction, who was successfully managed in a single session using a complete endoscopic approach with laser lithotripsy.

CASE SUMMARY

An 85-year-old female patient presented with 1-month history of intermittent abdominal pain, vomiting, decreased appetite and weight loss. An abdominal computed tomography showed a 4.5 cm × 4.7 cm partially calcified mass at the gastric pylorus causing gastric outlet obstruction. Endoscopy showed an ulcerated fistulous opening and a large 5 cm impacted gallstone in the duodenal bulb. Endoscopic nets and baskets were used in an attempt to remove the stone, but this approach was unsuccessful. Given her advanced age, poor physical condition and underlying comorbidities, she was deemed to be high-risk for surgery. Thus, a minimally invasive approach using endoscopic laser lithotripsy was attempted and successfully treated the stone. Post-procedure, the patient experienced complete resolution of her symptoms with no complications and was able to tolerate her diet. She was subsequently discharged home at 48 h, with an uneventful recovery.

CONCLUSION

In our paper we describe Bouveret syndrome and highlight its management with a novel endoscopic approach of laser lithotripsy in addition to various other endoscopic approaches available to date and its success rates.

Post-cholecystectomy Gallstone Ileus

Gallstone ileus is an unusual complication of cholelithiasis. Classically, a stone is impacted at the terminal ileum originating from a cholecystoduodenal fistula. Exceptions to this pathophysiology have been noted at each step. In this systematic review, we document a comprehensive review of postcholecystectomy gallstone ileus inclusive of 49 separate cases and report 8 different mechanisms leading to this unusual complication. The most common mechanism is a lost stone during cholecystectomy that then erodes through the intestinal wall leading to bowel obstruction. Our review showed an older, female predominance (64.0%) at an average age of 68.0 years, patients typically had a burden of comorbidities. Delay in diagnosis was common (64% of cases) with the correct diagnosis made in 37.5% of patients during admission. Pneumobilia was commonly reported (29.0%). There was a wide range in the amount of time between cholecystectomy and gallstone ileus, from 10 days to 50 years (mean 12.4 years). Postcholecystectomy gallstone ileus is an unusual complication of cholelithiasis, which mandates surgery. Retrieval of stones should be undertaken if they are spilled during cholecystectomy. Owing to the increasing age of the American patient population, it is likely that a higher number of patients with this condition will be encountered.

Gallstone Ileus: Management and Clinical Outcomes

Background: Gallstone or biliary ileus is a late complication of gallstone disease. It accounts for 1%-4% of all bowel obstructions and is more common in elderly patients. The preferred treatment option is to mechanically remove the impacted stones. It is done surgically using open or laparoscopic approach and rarely, when stones are impacted in the colon, endoscopically. In this paper we present five consecutive cases of gallstone ileus and describe possible diagnostic and minimally invasive treatment options. Case presentation: During a five-month period a total of five patients were treated for gallstone ileus. All patients were female and from 48 to 87 years of age. Symptoms were not specific and common for all small bowel obstructions. Upon admission the patients also had unspecific laboratory findings-neutrophilic leukocytosis and various C-reactive protein concentrations, ranging from 8 to 347 mg/L. According to the hospital protocol, all patients initially underwent an abdominal ultrasound, which was inconclusive, and therefore every patient additionally had a CT scan with intravenous contrast. After these two diagnostic modalities one patient still did not have the definitive gallstone ileus diagnosis, as the ectopic stone was not visible. Four patients in our case series were treated using minimally invasive methods: in one case the stone was removed endoscopically, and laparoscopically in the other three. Treatment outcomes were good in four cases as the patients fully recovered, however one patient suffered a massive cerebral infarction after the operation and passed away. Conclusions: Gallstone ileus is a rare and difficult-to-diagnose condition. Management of these patients in every case should be individualized, as there are many options, each with their own advantages and disadvantages. We show that minimally invasive treatment such as colonoscopy or laparoscopy is possible in these cases.

Cholecystolithotomy, a new approach to reduce recurrent gallstone ileus

The incidence of gallstone ileus (GSI) is increasing. Current treatment options include enterolithotomy with or without cholecystectomy and repair of the biliodigestive fistula. Although most surgeons defer the management of the biliodigestive fistula to avoid the associated morbidity and mortality, this can lead to increased rate of recurrence of GSI by the remaining gallstones. More than 130 cases of recurrent GSI were reported in published works, and the incidence of recurrent GSI is reported to be between 5% and 20%. Some cases of second recurrent attacks have also been reported. Most cases were reported in elderly women with faceted stones during the first 2 months from the first episode of GSI. This article reviews the current treatment options for more than 4,300 reported cases of GSI. A treatment algorithm is recommended based on the severity of the inflammation around the gallbladder, including cholecystolithotomy as a third treatment approach that aims to reduce the risk of recurrent GSI.

Making the invisible visible: improving conspicuity of noncalcified gallstones using dual-energy CT

PURPOSE

To determine whether virtual monochromatic imaging (VMI) increases detectability of noncalcified gallstones on dual-energy CT (DECT) compared with conventional CT imaging.

MATERIALS AND METHODS

This retrospective IRB-approved, HIPAA-compliant study included consecutive patients who underwent DECT of the abdomen in the Emergency Department during a 30-month period (July 1, 2013-December 31, 2015), with a comparison US or MR within 1-year. 51 patients (36F, 15M; mean age 52 years) fulfilled the inclusion criteria. All DECT were acquired on a dual-source 128 × 2 slice scanner using either 80/Sn140 or 100/Sn140 kVp pairs. Source images at high and low kVp were used for DE post-processing with VMI. Within 3 mm reconstructed images, regions of interest of 0.5 cm² were placed on noncalcified gallstones and bile to record hounsfield units (HU) at VMI energy levels ranging between 40 and 190 keV.

RESULTS

Noncalcified gallstones uniformly demonstrated lowest HU at 40 keV and increase at higher keV; the HU of bile varied at higher keV. Few of the noncalcified stones are visible at 70 keV (simulating a conventional 120 kVp scan), with measured contrast (bile-stone HU difference) <10 HU in 78%, 10-20 HU in 20%, and >20 HU in 2%. Contrast was maximal at 40 keV, where 100% demonstrated >20 HU difference from surrounding bile, 75% >44 HU difference, and 50% >60 HU difference. A paired t test demonstrated a significant difference (p < 0.0001) between this stone-bile contrast at 40 vs. 70 keV and 70 vs. 190 keV.

CONCLUSION

Low keV virtual monochromatic imaging increased conspicuity of noncalcified gallstones, improving their detectability.

Gallstone ileus associated with impaction at Meckel’s diverticulum: Case report and literature review

Gallstone ileus due to erosion of one or more gallstones into the gastrointestinal tract is an uncommon cause of small bowel obstruction. The site of impaction is usually distal ileum, and less commonly the jejunum, colon, duodenum, or stomach. We report a rare case of gallstone ileus with impaction at the proximal small bowel and at a Meckel’s diverticulum (MD) in a 64-year-old woman managed with laparoscopic converted to open small bowel resections. Patient was discharged home in stable condition and remained asymptomatic at 6-mo follow up. We review the current literature on surgical approaches to MD and gallstone ileus. Diverticulectomy or segmental resection is preferred for complicated MD. For gallstone ileus, simple enterolithotomy or segmental resection are the most the most favored especially in older co-morbid patients due to lower mortality rates and the rarity of recurrent gallstone ileus. In addition, laparoscopy has been increasingly reported as a safe approach to manage gallstone ileus.

[Enterolithotomy and early cholecystectomy, an application of damage control surgery for patients with gallstone ileus]

BACKGROUND

Recurrent gallstone ileus is an uncommon mechanical intestinal obstruction secondary to occlusion of the intestine by an intraluminal biliary calculus.

CLINICAL CASE

Female, 75 years old, ischaemic heart disease (stent), arrived in our department complaining of abdominal pain and vomiting. Computed tomography showed gallstone ileus. The patient underwent an enterotomy with gallstone removal. Three months later, the patient came back with the same clinical symptoms and signs. A new computed tomography highlighted a gallstone ileus again. Enterolithotomy and gallstone removal, cholecystectomy and closure of cholecystoduodenal fistula were performed. The patient had a prolonged hospital stay due to the development of congestive heart failure. Case 2. Male, 71 years old, ischaemic heart disease and aortocoronary bypass, seen in our department complaining of vomiting. Computed tomography showed aerobilia and gallstone ileus. The patient underwent an urgent enterolithotomy. Seven months later, the patient came back with the same clinical symptoms and signs. Computed tomography showed a new gallstone ileus. An enterotomy and gallstone removal, cholecystectomy and closure of cholecystoduodenal fistula were performed. The patient died due to multi-organ failure in post-surgery period.

CONCLUSION

In the elderly patients with concomitant medical illnesses with the risk of a second laparotomy, it is justifiable to reconsider the definitive repair in the treatment of gallstone ileus. The enterolithotomy in acute phase followed by early cholecystectomy (4-8 weeks) may be a safe method for eliminating, not only the possibility of recurrent gallstone ileus, and probably the need for a second laparotomy, but also the exceptional possibility of developing a gallbladder carcinoma.

Enterolithiasis

Enterolithiasis or formation of gastrointestinal concretions is an uncommon medical condition that develops in the setting of intestinal stasis in the presence of the intestinal diverticula, surgical enteroanastomoses, blind pouches, afferent loops, incarcerated hernias, small intestinal tumors, intestinal kinking from intra-abdominal adhesions, and stenosing or stricturing Crohn’s disease and intestinal tuberculosis. Enterolithiasis is classified into primary and secondary types. Its prevalence ranges from 0.3% to 10% in selected populations. Proximal primary enteroliths are composed of choleic acid salts and distal enteroliths are calcified. Clinical presentation includes abdominal pains, distention, nausea, and vomiting of occasionally sudden but often fluctuating subacute nature which occurs as a result of the enterolith tumbling through the bowel lumen. Thorough history and physical exam coupled with radiologic imaging helps establish a diagnosis in a patient at risk. Complications include bowel obstruction, direct pressure injury to the intestinal mucosa, intestinal gangrene, intussusceptions, afferent loop syndrome, diverticulitis, iron deficiency anemia, gastrointestinal hemorrhage, and perforation. Mortality of primary enterolithiasis may reach 3% and secondary enterolithiasis 8%. Risk factors include poorly conditioned patients with significant obstruction and delay in diagnosis. Treatment relies on timely recognition of the disease and endoscopic or surgical intervention. With advents in new technology, improved outcome is expected for patients with enterolithiasis.

Pneumobilia: a case report and literature review on its surgical approaches

Gallstones ileus is an uncommon cause but important cause of small bowel obstruction. The gallstone enters the intestinal lumen via a fistula located in the duodenum (cholecystoduodenal), or rarely, in the colon (cholecystocolonic) or stomach (cholecystogastric). This may result in large bowel or gastric outlet obstruction (Bouveret's Syndrome). Gallstone ileus affects the elderly females pre-dominantly and is associated with a high morbidity and mortality rate if diagnosis and urgent surgical intervention are delayed. In this paper, we report on the case of an elderly lady who presented with classical symptoms and signs of small bowel obstruction. She was subsequently diagnosed with gallstone ileus due to a large gallstones lodged in the intestinal lumen. We perform a literature review on this rare disease and discuss the two main surgical approaches in managing this condition. Gallstone ileus should be considered in the differential diagnosis of small bowel obstruction especially in elderly women who have no history of abdominal surgery or abdominal hernia. Early intervention is important because of the high mortality rate due to the poor general condition that often exists in this subgroup of patients. There is no general consensus on gold standard surgical approach in these cases but a two-stage procedure (either enterotomy alone or enterotomy and subsequent cholecystectomy) has been shown to be associated with lower mortality rates.

Usefulness of CT-scan in the diagnosis and therapeutic approach of gallstone ileus: report of two surgically treated cases

BACKGROUND

Gallstone ileus is a rare cause of gastrointestinal obstruction, more frequent in elderly patients, whose treatment is essentially surgical, although some para-surgical and mini-invasive possibilities exist, allowing the solution of such obstructive condition in a completely non-invasive way.

DESCRIPTION

In our study, after reporting two cases of biliary ileus managed by our surgical division, we will analyze the most suitable diagnostic procedures and the therapeutic approaches to this pathology.

CONCLUSIONS

Gallstone ileus is a quite rare pathology in population, but affects more frequently elderly people; The treatment of this disease is mainly surgical.

[Gallstone ileus as a cause of acute abdomen. Importance of early diagnosis for surgical treatment]

Gallstone ileus is an uncommon type of mechanical intestinal obstruction caused by an intraluminal gallstone, and preoperative diagnosis is difficult in the Emergency department. This study is a retrospective analysis of the clinical presentation of 5 patients with gallstone ileus treated between 2000-2010. Clinical features, diagnostic testing, and surgical treatment were analyzed. Five patients were included: 2 cases showed bowel obstruction; 2 patients presented a recurrent gallstone ileus with prior surgical intervention; and one patient presented acute peritonitis due to perforation of an ileal diverticula. In all cases CT confirmed the preoperative diagnosis. In our experience, gallstone ileus may present with clinical features other than intestinal obstruction. In suspicious cases CT may be useful to decrease diagnostic delay, which is associated with more complications.

Gallstone ileus: revisiting surgical outcomes using National Surgical Quality Improvement Program data

BACKGROUND

Although surgical management remains the mainstay of therapy for gallstone ileus, the optimal approach--enterolithotomy alone or combined with biliary-enteric fistula disruption--is controversial because of the reliance on small single-center series to describe outcomes. Using the American College of Surgeons' National Surgical Quality Improvement Program database, we sought to (1) review the outcomes of patients undergoing surgical management of gallstone ileus and (2) determine if cholecystectomy in addition to enterolithotomy increased morbidity or mortality rate.

METHODS

We analyzed the demographics, comorbidities, acuity, operative time, postoperative hospitalization length, and 30-d morbidity and mortality rates of 127 patients from 2005 to 2010 who underwent a procedure for the relief of gallstone ileus. We identified a subset of 14 patients who underwent simultaneous cholecystectomy. We compared the "no cholecystectomy" and "cholecystectomy" groups using standard statistical methods.

RESULTS

The overall 30-d postoperative morbidity and mortality rate was 35.4% and 5.5%, respectively. Superficial surgical site infection and urinary tract infection were the most common complications. There was no significant difference in mortality rate between the no cholecystectomy and the cholecystectomy groups (5.3% versus 7.1%, respectively; P = 0.78), but the latter group did experience more minor complications, longer operations, and longer postoperative hospitalization.

CONCLUSIONS

Other recent studies on this topic have collected data or reviewed literature across several decades, making this study in particular one of the largest truly modern series. Perhaps reflecting changes in perioperative management, surgical treatment of gallstone ileus is less morbid than previously described, but there is still insufficient evidence to favor concurrent cholecystectomy.

Cholecystogastric fistula: a brief report and review of the literature

Cholecystogastric fistula is a rare, life-threatening complication of cholelithiasis that presents a difficult challenge to the surgeon when it occurs in elderly and co-morbid patients. Following a case of a 68-year-old female who presented with a short history of epigastric pain and vomiting, and in whom a cholecystogastric fistula was identified on abdominal computed tomography and confirmed on upper gastrointestinal endoscopy, we performed a systematic review of the literature on the management of cholecystogastric fistula. Our patient underwent laparotomy without excision of the fistula nor cholecystectomy and had an uncomplicated post-operative course. Surgical management using an open approach remains the mainstay of treatment of cholecystogastric fistula although laparoscopic techniques are used with increasing success. Surgical closure of the fistula is not always necessary. Improved surgical techniques including the use of laparoscopic surgery have led to improved outcomes in the management of cholecystogastric fistula.

A peculiar cause of bowel obstruction

INTRODUCTION

Gallstone disease is one of the most common surgical problems necessitating intervention. It is estimated that approximately 15% of people in the western world will develop gallstones. Of these patients, 35% of patients initially diagnosed with gallstones will later develop a complication which will eventually result in cholecystectomy.(2) One of these complications is gallstone ileus, which is a rare complication associated with high morbidity and mortality, and the diagnosis is often missed.(3)

PRESENTATION OF CASE

A 66 year old female presented with an acute onset of "colicky" abdominal pain accompanied with vomiting. She had known gallstones diagnosed previously by ultrasound. Her abdomen was generally tender with guarding of the right hypochondrium and absent bowel sounds.

DISCUSSION

Gallstone ileus accounts for 0.5-4% of all cases of small bowel obstruction, and typically affects females over the age of 65.(3,4) The pathophysiological basis of the disease involves fistulation of the gallstone through the wall of the gallbladder into the bowel, where it becomes impacted and leads to obstruction. Mortality of the condition is not sufficiently reported, but surgical intervention in itself conveys significant morbidity, and mortality has been reported to be 18%.(3,9)

CONCLUSION

We report a single large gallstone, which we believe to be one of the largest documented in recent literature, resulting in gallstone ileus. We also present a brief synopsis of the diagnosis and management of the condition, which although rare, should be considered by the astute surgical trainee.

Complicated cholelithiasis: an unusual combination of acute pancreatitis and bouveret syndrome

Bouveret syndrome is a rare form of gallstone ileus. The purpose of the present study was to present the unusual case of a female patient with complicated cholelithiasis manifested as a combination of acute pancreatitis and concomitant Bouveret syndrome. A 61-year-old female patient was admitted to the emergency department complaining of mid-epigastric and right upper quadrant abdominal pain radiating band-like in the thoracic region of the back as well as repeated episodes of vomiting over the last 24 h. The initial correct diagnosis of pancreatitis was subsequently combined with the diagnosis of Bouveret syndrome as a computed tomography scan revealed the presence of a gallstone within the duodenum causing luminal obstruction. After failure of endoscopic gallstone removal, a surgical approach was undertaken where gallstone removal was followed by cholecystectomy and restoration of the anatomy by eliminating the fistula. The concomitant pancreatitis complicated the postoperative period and prolonged the length of hospital stay. However, the patient was discharge on the 45th postoperative day. Attempts for endoscopic removal of the impacted stone should be the initial therapeutic step. Surgery should be reserved for cases refractory to endoscopic intervention and when definite treatment is the actual challenge.

Totally laparoscopic management of gallstone ileus--technical report and review of the literature

PURPOSE

Gallstone ileus is an uncommon complication of gallstone disease. It occurs in elderly patients in up to 25% of the cases. The management of gallstone ileus remains controversial. Open surgery has been the mainstay of treatment, but laparoscopic surgery has recently been used. In this study we report a case of an 87-year-old female patient with gallstone ileus who has been managed totally laparoscopically, detailing the technique and discussing the advantages of the laparoscopic approach with a review of the literature.

METHODS

The pneumoperitoneum was established with a Veress needle. A three-port approach (one 5-mm and two 10-mm trocars) and a 30° 10-mm laparoscope were used. The site of obstruction was 5 cm below the ligament of Treitz, and a single gallstone was identified. A 3-cm longitudinal enterotomy was created just above the site where the gallstone was located. An 8-cm-long gallstone was extracted. The enterotomy was closed transversely in a single layer of two sets of continuous sutures.

RESULTS

The procedure was safely performed with all the advantages of minimally invasive surgery. Previous studies often described laparoscopically assisted procedures for the treatment of gallstone ileus, using a small abdominal incision. In recent years, some reports have been published on the efficacy of the totally laparoscopic approach in the management of gallstone ileus.

CONCLUSIONS

Totally laparoscopic management of gallstone ileus could be safe and effective with suggested benefits for the elderly patients.

A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy

INTRODUCTION

Gallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported.

PRESENTATION OF CASE

We report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy.

DISCUSSION

Laparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract.

CONCLUSION

Endoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery.

Once bitten, twice incised: recurrent gallstone ileus

Uncommon causes of small bowel obstruction can provide interesting surgical decision-making challenges. This report describes a patient with recurrent gallstone ileus. According to most current reviews, erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus appears to be the most appropriate decision. Although a rare scenario, the situation of recurrent gallstone ileus presents an interesting learning opportunity. It is important to keep in mind the need for complete examination of the abdomen. Furthermore, evacuation of any remaining stones from the gallbladder is imperative if possible. Erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus has been shown to be a safe and effective treatment decision over a single-stage removal of the stone with closure of the cholecystoduodenostomy.

[Gallstone ileus in underlying stenosis of the sigmoid due to recurrent diverticulitis--a rare complication of cholelithiasis]

BACKGROUND

Gallstone ileus is a rare complication of cholelithiasis and an uncommon cause of intestinal obstruction. It accounts for about 1-4% of all mechanical bowel obstructions. The clinical symptoms and signs of gallstone ileus are mostly nonspecific.

CASE REPORT

An 82-year-old woman with recurrent diverticulitis of the sigmoid was admitted because of cramping right upper abdominal pain and signs of large bowel obstruction. Abdominal ultrasound revealed pneumobilia and severe diverticulitis of the sigmoid with signs of ileus. Endoscopic retrograde cholangiography visualized the cholecystoenteric fistula. In addition, computed tomography (CT) scan revealed two stones 3 cm in diameter leading to nearly complete obstruction of the sigmoid. The patient underwent an open cholecystectomy, closure of the cholecystoenteric fistula, and sigmoidectomy.

CONCLUSION

This case report demonstrates that relative stenoses of the sigmoid due to recurrent diverticulitis may predispose to the impaction of foreign bodies. Gallstone ileus is a rare but important differential diagnosis of intestinal obstruction. Ultrasound and CT scans are very helpful in diagnosing gallstone ileus. The treatment is surgical. Unfortunately, surgical therapy of this rare complication is associated with a high morbidity and mortality rate due to multiple comorbidities and age-related problems of these patients. The management of patients with gallstone ileus should be individualized.

Surgical treatment of gallstones

Currently there is no evidence for prophylactic cholecystectomy to prevent gallstone formation (grade B). Cholecystectomy cannot be recommended for any group of patients having asymptomatic gallstones except in those undergoing major upper abdominal surgery for other pathologies (grade B). Laparoscopic cholecystectomy is the preferred treatment for all patient groups with symptomatic gallstones (grade B). Patients with gallstones along with common bile duct stones treated by endoscopic sphincterotomy should undergo cholecystectomy (grade A). Laparoscopic cholecystectomy with laparoscopic common bile duct exploration or with intraoperative endoscopic sphincterotomy is the preferred treatment for obstructive jaundice caused by common bile duct stones, when the expertise and infrastructure are available (grade B).

The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification

BACKGROUND

Mirizzi syndrome and cholecystoenteric fistula with or without gallstone ileus are late complications of gallstone disease. We previously suggested that the natural history of Mirizzi syndrome may not end with just a cholecystobiliary fistula and that the continuous inflammation in the triangle of Calot area may result in a complex fistula involving the biliary tract and the adjacent viscera. The purpose of this study was to establish the relationship of Mirizzi syndrome with cholecystoenteric fistulas.

METHODS

We retrospectively reviewed the records of all patients older than aged 18 years submitted to emergency or elective cholecystectomy from 1995 to 2006. Of 5,673 cholecystectomies performed during that period, we found 327 (5.7%) patients with Mirizzi syndrome and 105 (1.8%) patients with cholecystoenteric fistula. Ninety-four (89.5%) patients with cholecystoenteric fistula also had an associated Mirizzi syndrome.

RESULTS

Cholecystoenteric fistula was associated with Mirizzi syndrome (p < 0.0001), increased age was associated with Mirizzi syndrome and cholecystoenteric fistula (p < 0.0001), and female gender was associated with Mirizzi syndrome (p < 0.0001).

CONCLUSION

When during surgery for gallstone disease a cholecystoenteric fistula is encountered, the possibility of an associated Mirizzi syndrome must be considered. The findings of this study confirm the association of Mirizzi syndrome with cholecystoenteric fistula.

The oldest patient with gallstone ileus: report of a case and review of 176 cases in Japan

We report a 91-year-old woman presenting bowel obstruction due to impacted gallstone, who was the oldest patient which has been reported in Japanese scientific literature. The patient was referred to our hospital due to vomiting and abdominal pain. Computed tomography and abdominal X-ray showed dilated loops of small intestine associated with air-fluid levels, pneumobilia, and a calcified mass in the left iliac fossa. After the diagnosis of bowel obstruction due to gallstone was made, an enterotomy and lithotomy was performed under spinal anesthesia. The postoperative recovery was uneventful. We also reviewed 176 cases of gallstone ileus which were reported in the Japanese literature in the past 20 years. The retrospective analysis demonstrated that one-stage enterolithotomy alone may be acceptable as the first choice of operative treatment. The gallstone ileus is a rare, but important disease because urgent and appropriate surgical therapy is required.

Cholecystocolonic fistula: facts and myths. A review of the 231 published cases

BACKGROUND

Cholecystocolonic fistula (CCF) is the second most common cholecystoenteric fistula and is often discovered intraoperatively, resulting in a challenging situation for the surgeon, who is forced to switch to a complex procedure, often in old, unfit patients. Management of this uncommon but possible finding is still ill defined.

METHODS

An extensive review of 160 articles published from 1950 to 2006 concerning 231 cases of CCF was performed.

RESULTS

CCF is mostly an affliction of women in their sixth to seventh decades and is rarely diagnosed preoperatively. Chronic diarrhea is the key symptom in nonemergency patients, but, in one-fourth of cases, CCF presents with an acute onset, mostly biliary ileus. In one-fourth of patients, a second hepatobiliary abnormality is present, including gallbladder cancer in 2% of cases. In uncomplicated cases, diverting colostomy is not performed anymore, and laparoscopy treatment has been described in specialized centers. Symptomatic treatment of concomitant biliary ileus (without treating CCF) is a feasible option. Resolution of colonic biliary ileus by interventional endoscopy is reported.

CONCLUSION

CCF should be considered in differential diagnosis of diarrhea, especially in old, female patients. A possible second hepatobiliary abnormality should be always investigated. Extemporaneous frozen section should be performed if gallbladder cancer is suspected. Depending on clinical presentation, different treatments for CCF are indicated, ranging from minimally invasive procedures to extensive resection.

Gallstone ileus: surgical strategies and clinical outcome

OBJECTIVE

Gallstone ileus is a rare cause of intestinal obstruction affecting mainly the elderly. This study aimed to analyze the surgical treatments and outcome of the disease.

METHODS

We present a retrospective study of 13 patients diagnosed with gallstone ileus from January 2000 to December 2005 in our hospital and a review of the published literature.

RESULTS

Three men and 10 women participated in the study, with a mean age of 74.3 (range: 63-85). The mean duration of symptoms was 6 days (range 2-14). A pre operative diagnosis was made in 10 patients. The mean delay in diagnosis was 3.5 days (range 1-10). Ten patients had an enterolithotomy (E) and three patients had a one-stage procedure comprising enterolithotomy, cholecystectomy and fistula repair (EC). There was no postoperative mortality in either group. The mean postoperative hospital stay for group E was 14 (range 6-31) days and for group EC was 19 (range: 5-28) days. Twelve patients were alive at the time of review. One patient from group E died of unrelated causes after three years. One patient in group E developed cholangitis but no surgical intervention was required on case note review over a mean postoperative period of 3.4 years.

CONCLUSION

E alone is best suited in all elderly gallstone ileus patients with significant comorbidities. A one-stage procedure (EC) should be reserved for young, fit and low risk patients.

Intermittent gastric outlet obstruction due to a gallstone migrated through a cholecysto-gastric fistula: A new variant of “Bouveret’s syndrome”

Bouveret’s syndrome, defined as gastric outlet obstruction due to a large gallstone, is still one of the most dramatic biliary gallstone complications. Although new radiological and endoscopic techniques have made pre-surgical diagnosis possible in most cases and the death rate has dropped dramatically, “one-stage surgery” (biliary surgery carried out at the same time as the removal of the gut obstruction) should be still considered as the gold standard for the treatment of gallstone ileus.In this case, partial gastric outlet obstruction resulted in an atypical and insidious clinical presentation that allowed us to perform the conventional one-stage laparatomic procedure that completely solved the problem, thus avoiding any further complications.

Bouveret syndrome and gallstone ileus

Intestinal obstruction from gallstones is a rare complication of gallstone disease. These ectopic gallstones can cause obstruction anywhere from the duodenum to the colon and are accompanied by a cholecystoduodenal/enteric/colic fistula. We report an 81-year-old male who presented with gallstone obstruction of the duodenum who underwent attempted endoscopic fragmentation and extraction that eventually led to small bowel obstruction from an impacted fragment of the stone. He underwent successful enterolithotomy and has been asymptomatic from the cholecystoduodenal fistula. Surgery is the gold standard for the treatment of this condition but the extent of the operation remains a matter of debate.

Endoscopically assisted minimally invasive surgery for gallstones

BACKGROUND

We present a case report of Bouveret syndrome followed by a review of the recent literature regarding the management of this condition. Bouveret syndrome is a form of gastric outlet obstruction secondary to a gallstone which has eroded through the gallbladder into the duodenum. It is an uncommon variant of gallstone ileus. Endoscopic methods have been described to extract the stone from the duodenum.

METHODS

This is a case of an 85-year-old female patient who presented with a 1-week history of nausea, intermittent bilious vomiting and anorexia. Imaging confirmed the diagnosis of Bouveret syndrome caused by two large gallstones. Conventional endoscopic methods successfully extracted the impacted stones from the duodenum into the stomach but were unable to extract the stones from the stomach. A mini-transverse laparotomy and gastrotomy were performed to finally extract the stones.

Internal biliary fistula due to cholelithiasis: A single-centre experience

AIM: To discuss about the perioperative problems encountered in patients with internal biliary fistula (IBF) caused by cholelithiasis.

METHODS: In our hospital, 4 130 cholecystectomies were carried out for symptomatic cholelithiasis from January 2000 to March 2004 and only 12 patients were diagnosed with IBF. The perioperative data of these 12 IBF patients were analyzed retrospectively.

RESULTS: The incidence of IBF due to cholelithiasis was nearly 0.3%. The mean age was 57 years. Most of the patients presented with non-specific complaints. Only two patients were considered to have IBF when gallstone ileus was observed during the investigations. Nine patients underwent emergency laparotomy with a pre-operative diagnosis of acute abdomen. In the remaining three patients, elective laparoscopic cholecystectomy was converted to open surgery after identification of IBF. Ten patients had cholecystoduodenal fistula and two patients had cholecystocholedochal fistula. The mean hospital stay was 13 d. Two wound infections, three bile leakages and three mortalities were observed.

CONCLUSION: Cholecystectomy has to be performed in early stage in the patients who were diagnosed as cholelithiasis to prevent the complications like IBF which is seen rarely. Suspicion of IBF should be kept in mind, especially in the case of difficult dissection during cholecystectomy and attention should be paid in order to prevent iatrogenic injuries.

Gallstone Ileus: Diagnosis and Management

BACKGROUND

Gallstone ileus is a rare complication of cholelithiasis, mostly in the elderly. It accounts for 1%-4% of mechanical bowel obstruction and is associated with high morbidity and mortality. We present our experience of gallstone ileus and discuss current opinion as reported in the literature.

PATIENTS AND METHODS

A retrospective review was performed of medical records of patients in our institution coded for gallstone ileus by the International Classification of Diseases (ICD K-563) coding system between January 1998 and December 2005.

RESULTS

There were 22 patients with mean age of 77 (58-92) years and a female to male ratio of 4.5:1. Most patients presented with abdominal pain and vomiting, with a median duration of symptoms of 3 (1-28) days. Preoperative diagnosis was made in 77% from a combination of plain x-ray, ultrasonography, and computed tomography (CT) scans; 86.4% of the patients belonged to ASA class of 3 or 4. Twenty patients underwent enterolithotomy alone, and two had one-stage procedure. The mean size of impacted stones was 3.6 (2.5-4.5) cm, with location in the terminal ileum in 17 and jejunum in 5 patients. There were 5 perioperative deaths and an episode of cholangitis occurring in one patient 18 months after enterolithotomy alone.

CONCLUSIONS

Gallstone ileus is a difficult clinical entity to diagnose. Unreserved use of imaging techniques can improve diagnostic accuracy and speed of therapeutic decision making. Management of gallstone ileus must be individualized. The one-stage procedure should be offered only to highly selected patients with good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation.

Role of helical CT in diagnosis of gallstone ileus and related conditions

OBJECTIVE

Small-bowel obstruction from gallstone impaction is a pathological entity frequently observed in elderly patients with a history of cholelithiasis or cholecystitis. Diagnostic imaging plays a great role in the management of patients with suspected gallstone ileus and overall in the correct predictive diagnosis: in the last years, some experiences in radiologic diagnosis of this entity by sonography, abdominal plain film and CT, and occasionally MRI have been reported. Some questions related to gallstone ileus are to be considered: one of them is the possibility of recurrence, which increases the operatory risk in these patients. Recurrence may be due either to the presence of overlooked stones that were already in the bowel at the time of surgery but not identified and not removed or to the migration of other stones in patients not previously cholcystectomized. In cases of acute abdomen, establishing an effective conservative therapy may be a critical point. The aim of this retrospective study was to evaluate the capabilities of helical single-detector and MDCT scanners to allow a correct diagnosis of this disease.

CONCLUSION

Helical single-detector and MDCT may improve the diagnosis of gallstone ileus, providing important information regarding the exact number, size, and location of ectopic stones and the site of intestinal obstruction or direct visualization of a biliary-enteric fistula, to help clinicians in the therapeutic management of patients.

Successful Treatment of Bouveret Syndrome Using Holmium: YAG Laser Lithotripsy

Although gallstone disease is highly prevalent, cholelithiasis causing gallstone ileus is uncommon. Consideration has been given for nonoperative strategies to resolve obstruction due to the significant age and comorbidities afflicting this population. A 94-year-old man presented with a 5-day history of abdominal distension and tenderness. CT scan revealed multiple large gallstones within the gallbladder, pneumobilia, and two ectopic gallstones (antrum of the stomach and distal ileum). The patient was taken to the operating room where an enterolithotomy and gastrotomy was performed with removal of gallstones and subsequent relief of obstruction. During the postoperative course, the patient developed symptoms of gastric outlet obstruction and underwent gastrointestinal endoscopy for diagnosis and treatment. Two large gallstones, present in the duodenum, were retracted into the stomach using a Roth net but could not be retrieved beyond the upper esophageal sphincter. A holmium: yttrium-aluminum-garnet (Holmium: YAG) laser was used for fragmentation of the stones, with subsequent successful removal. This is the first documented successful use of the holmium: YAG laser for the treatment of recurrent gallstone ileus. Physicians should remember that in a small but important subgroup of patients, endoscopy accompanied by laser lithotripsy may prove beneficial.

Gallstone ileus masquerading as an obstructed femoral hernia

Gallstone ileus affects primarily elderly women. In many instances, no history of previous biliary disease is discernible. Although it has been known since the 17th century, gallstone ileus continues to present in such an intriguing way that, more often than not, the diagnosis is made intraoperatively. A 68‐year‐old woman, presented with abdominal pain and vomiting. She had a slightly distended and mildly tender abdomen, and the bowel sounds were normal. There was an irreducible, slightly tender right femoral hernia. Plain X‐rays of the abdomen were normal and an ultrasound showed a contracted fibrotic gall bladder with small stones. Laparoscopy failed to detect an obstructing gallstone, which was discovered in a second laparotomy. Cholecystectomy and fistula closure were carried out in the same sitting. A retrospective review of a preoperative Gastrografin study showed clear radiological evidence of the condition. Gallstone ileus tends to be forgotten as a cause of bowel obstruction or abdominal pain in elderly women. With this in mind, careful interpretation of a Gastrografin study might provide the diagnosis preoperatively. In relatively fit patients, cholecystectomy and fistula closure could be safely added to the emergency enterolithotomy.