Gallstone Ileus Caused by Cholecystocolonic Fistula and Gallstone Impaction in the Sigmoid Colon: Review of the Literature and Novel Surgical Treatment with Trephine Loop Colostomy

Intestinal obstruction induced by gallstone migration through unusual location of a cholecystogastric fistula: A rare case report

INTRODUCTION

Gallstone ileus is a rare condition resulting from cholelithiasis, associated with the formation of a fistula between the gallbladder and the intestinal tract. It is responsible for less than 0.1 % of cases of mechanical bowel obstruction.

PRESENTATION OF CASE

A 54-year-old male with hypertension presented with symptoms of intestinal obstruction, including inability to pass stool, anorexia, abdominal pain, vomiting, and oliguria. Physical examination revealed epigastric tenderness and a distended abdomen without jaundice. Laboratory tests indicated mild anemia. The patient initially refused any surgical interventions, so he was placed on conservative treatment for 24 h. Subsequently, an emergency exploratory open laparotomy was performed, revealing a gallstone causing small bowel obstruction. A constricted ileal loop, 15 cm in length, with stone impaction was resected, and an end-to-end anastomosis was performed. A cholecystogastric fistula was identified and repaired, and a retrograde cholecystectomy was performed. The patient recovered without complications.

DISCUSSION

Gallstone ileus occurs when a fistula develops between the gallbladder and the intestinal tract. Notably, the presence of a fistula connecting the gallbladder and stomach ranges from 0 % to 13.3 %. Cholecystoenteric fistulas (CEFs) typically occur in elderly women in their seventh or eighth decade of life. Diagnosis often relies on CT scanning, and surgical intervention remains the primary treatment. Interestingly, despite improved awareness and imaging techniques, some cases are still discovered incidentally during surgery.

CONCLUSION

This case highlights the diagnostic and therapeutic challenges posed by gallstone ileus, and emphasizes the importance of considering gallstone-related disorders in differential diagnoses for acute abdominal obstruction.

Like a Rolling (Gall)Stone: Optimal Treatment of Gallstone Obstruction of the Sigmoid Colon

BACKGROUND

Sigmoid gallstone ileus is a rare complication of cholelithiasis, accounting for 1-4% of all cases of large-bowel obstruction. This is a highly morbid, and often fatal, condition due to its challenging diagnosis and late presentation.

CASE PRESENTATION

We report a case of a 90-year-old woman admitted to Emergency Department with abdominal pain and large-bowel obstruction due to a 6 cm gallstone lodged in a diverticulum of the proximal sigmoid colon as a consequence of a cholecysto-colonic fistula. Colonoscopy was deferred due to gallstone size carrying a high possibility of failure. The patient underwent urgent laparotomy with gallstone removal via colotomy. The cholecystocolonic fistula was left untreated. The post-operative course was uneventful; the patient was discharged on 6th post-operative day.

CONCLUSION

A multidisciplinary discussion between endoscopists and surgeons is often needed to choose the best therapeutic option, especially in high-risk patients.

Laparoscopic management of combined cholecystogastric and cholecystocolonic fistulae

Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.

Non-operative management of gallstone sigmoid ileus in a patient with a prostatic cancer

Gallstone ileus is an uncommon complication of calculus cholecystitis through the formation of a biliary enteric fistula. The risk of mechanical obstruction caused by gallstones is increased with its size, in addition to chronic constipation, neoplasm and diverticulitis, to name a few. Here, we present a case of an 89-year-old male patient who presented with signs of bowel obstruction, which was found to be a gallstone impacted in the sigmoid colon. Considering the patient's stable condition and his comorbidities, a conservative approach was opted including IV fluids, fleet enema and bowel rest. Colonoscopy was performed and confirmed the passage of the stone. With no consensus regarding the management, the literature emphasizes a tailored approach to each case considering all possible operative and non-operative approaches. Some reports show promising results with non operative management. Gallstone ileus remains a challenging case, and further studies for the best treatment modalities are needed.

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.

Gallstone Ileus—Lessons from a Missed Diagnosis

Gallstone ileus is an uncommon presentation in patients with acute abdomen. Its diagnosis and treatment are often delayed due to its nonspecific clinical presentation. Presence of gallstone in ileum can be difficult to detect on computed tomography (CT) as mostly they are lucent. We report the case of a 66-year-old man with a 1-day history of vomiting and abdominal bloating. Initial CT could not identify the obstructing gall stone. On the follow-up CT, there was a distal shift of obstruction site in the intestine raising suspicion of a gallstone. We discuss the imaging findings on CT and the clues to diagnosing gallstone ileus.

Surgical Management of Cholecystoenteric Fistula in Patients With and Without Gallstone Ileus: An Experience of 29 Cases

Background

Cholecystoenteric fistula (CEF) is an uncommon complication of cholelithiasis. Here, we report our experience on diagnostic methods and surgical management of CEF patients with and without gallstone ileus (GI).

Methods

This is a retrospective cases series over an 11-year period (2011–2022). Data analyzed included preoperative characteristics, ultrasound, imaging features, operation findings and postoperative course.

Results

A total of 29 patients diagnosed with CEF were enrolled, 51.7% (15/29) of whom were female, with a median age of 66 years (range: 35–96 years). With regards to subtype distribution, seventeen patients had cholecystoduodenal fistula (CDF), six had cholecystoconlonic fistula (CCF), three exhibited cholecystogastric fistula (CGF), one CDF combination with CCF and two CDF combination with type I Mirizzi syndrome. Twelve patients presented with gallstone ileus, and received one stage procedure or simple Enterolithotomy. The median operation time and blood loss of 157 min (range: 65–360 min) and 40 ml (range: 10–450 ml), respectively. Surgical complications, evidenced by fistula recurrence, were recorded in three patients (3/22; 13.6%), while four (4/29; 13.8%) and one patient (1/29; 3.4%) presented with wound infection and residual stone in common bile duct, respectively. No deaths were reported in our study.

Conclusion

CEF is a rare complication of gallstone disease that is occasionally found during operation. To date, no consensus has been reached regarding efficacious treatment therapies for CEF patients. For a CEF patient with GI, one stage procedure should be selected prudently, while simple Enterolithotomy would be a mainstream choice for relieving bowel obstruction.

Incidental cholecystocolonic fistula in obstructive jaundice

Cholecystocolonic fistula is a rare condition often diagnosed intraoperatively, requiring an adequate set of knowledge and skills to allow safe intraoperative change of prior planned surgery and alleviate significant morbidity.

Cholecystocolonic fistula with a giant colonic gallstone: the mainstay of treatment in an acute setting

A cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis with cholecystitis. Cholecystocolonic fistulas (CCFs) account for 8–26.5% of all CEFs. CCFs can cause colonic bleeding, obstruction or perforation, with such complications being mainly reported in the narrower sigmoid colon. Colonic biliary ileus, or obstruction due to the colonic gallstone impaction, is extremely rare in the proximal colon and its best management is yet to be elucidated. We present the case of a 73-year-old male patient with multiple comorbidities and previous abdominal surgeries who presented with hematochezia and intestinal obstructive symptoms. Imaging revealed a giant 5 × 7 cm² gallstone in the proximal transverse colon. Laparotomy and stone extraction via colotomy were performed. Complicated proximal colonic gallstones are exceedingly rare with several operative and non-operative treatments already described. A time-saving surgery in a patient with serious comorbidities is reasonable when compared to a more extensive procedure including enterolithotomy, cholecystecomy and fistula closure.

Gallstone ileus of the sigmoid colon caused by cholecystocolonic fistula: A case report

INTRODUCTION

A cholecystocolonic fistula (CCF) is a late complication following repeated episodes of chronic inflammation of the gallbladder in contact with the hepatic flexure, and it might cause a biliary ileus in the colon, causing an intestinal obstruction, and if left untreated, a life threatening disease.

PRESENTATION OF CASE

a 49-year-old female patient presented with abdominal pain and bowel obstruction due to a gallstone impaction on the sigmoid colon as consequence of a cholecystocolonic fistula. An enterolithotomy was performed, and the patient evolved favorably. She was discharged without complications on the 5th Postoperative day (POD).

DISCUSSION

Clinical signs of CCF are usually minimal, and a preoperative diagnostic of CCF is rare, and it often presents with abdominal pain, nausea, vomiting, diarrhea, weight loss, and malabsorption. In the vast majority of patients presenting with CCF and biliary ileus, the stone is located within the sigmoid colon, accompanied with a concomitant disease at this point, with diverticulosis being the most common occurrence.

CONCLUSION

A cholecystocolonic fistula with a gallstone colonic ileus must be suspected in an elderly, and female, patient presenting with cholelithiasis and with intestinal obstruction. Treatment should not be delayed, and correction of the intestinal obstruction ought to be the basis of the treatment.

Clinical and radiological diagnosis of gallstone ileus: a mini review

Gallstone ileus is a rare cause of bowel obstruction, which mainly affects the elderly population. The associated mortality is estimated to be up to 30%. The presentation of gallstone ileus is notoriously non-specific, and this often contributes to the delay in diagnosis. The diagnosis of gallstone ileus relies on a radiological approach, and herein we discuss the benefits and drawbacks of the use of different modalities of radiological imaging: plain abdominal films, computed tomography, magnetic resonance imaging, and ultrasound scanning. Based on our case experience and review of the literature, the authors conclude that although an effective first-line tool, plain abdominal films are not adequate for diagnosing gallstone ileus. In fact, the gold standard in an acutely unwell patient is computed tomography.

A systematic review of gallstone sigmoid ileus management

INTRODUCTION

Gallstone sigmoid ileus is a rare although serious complication of cholelithiasis resulting in large bowel obstruction. The condition accounts for 4% of all gallstone ileus patients. There are no recognized management guidelines currently. Management strategies range from minimally invasive endoscopy and lithotripsy to substantial surgery. We aim to identify trends when managing patients with gallstone sigmoid ileus to help improve outcomes.

METHODS

Literature searches of EMBASE, Medline and by hand were conducted. All English language papers published from 2000 to 2017(Oct) were included. The terms 'gallstone', 'sigmoid', 'colon', 'ileus', 'coleus' and 'large bowel obstruction' were used.

RESULTS

38 papers included, male:female ratio was 8:30. Average age was 81.11 (SD ± 7.59). Average length of preceding symptoms was 5.31days (+/-SD3.16). 20/38 (59%) had diverticulosis. 89% of patients had significant comorbidities documented. 34/38 patients underwent computerized tomography. 31 stones were located within sigmoid colon, 4 at rectosigmoid junction and 2 within descending colon. Average impacted gallstone size was 4.14 cm (2.3-7 cm range). 23/38 (61%) patients' initial management was conservative or with endoscopy ± lithotripsy. Conservative management successfully treated 26% of patients. 28/38 (74%) patients ultimately underwent surgical intervention. 5/38 patients died post-operatively. Patients treated non-operatively had shorter hospital stays (4:12.3days) although not significant (p-value = 0.0056).

CONCLUSIONS

There is no management consensus from the literature. Current evidence highlights endoscopy and lithotripsy as practical firstline strategies. However, surgical intervention should not be delayed if non-operative measures fail or in emergency. Given the complexity of such patients, less invasive timesaving surgery appears practical, avoiding bowel resection and associated complications.