Gallstone ileus: Report of two cases and review of the literature

Gallstone ileus: An unusual complication of cholelithiasis in a 42-year-old female with no comorbidities

INTRODUCTION AND IMPORTANCE

Gallstone ileus is a rare condition, accounting for 0.5 % of mechanical small bowel obstructions. It is a misnomer for mechanical intestinal obstruction caused by one or more gallstones impacted within the gastrointestinal tract lumen, which occurs mostly in the elderly and female population. Treated usually by operative enterolithotomy. Preoperative diagnosis is challenging, but CT, which is investigation of choice, and magnetic resonance imaging (MRI) have made it easier to diagnose.

CASE PRESENTATION

A 42-year-old female presented to the emergency department with epigastric abdominal pain for 1 week, preceded by 2 months of RUQ pain. CT scan with contrast showed a classical finding of small bowel obstruction and ectopic gallstone. An emergency exploratory laparotomy, enterolithotomy, and cholecystectomy with fistula repair were performed in one surgical stage.

CLINICAL DISCUSSION

Laparoscopic enterolithotomy alone is the most preferred method due to its low incidence of complications but one-stage or two-stage surgeries are also options, but the choice between surgical modalities depends on the patient's status.

CONCLUSION

Gallstone ileus mostly affects older female patients who have a history of gallbladder disease and often have a poor prognosis that becomes worse with age and comorbidities. However, this was a young female patient with no comorbidities, which may affect the prognosis compared to those who are at risk for gallstone ileus.

Gallstone Ileus: Clinical Presentation and Radiological Diagnosis

The term "gallstone ileus" refers to intestinal obstruction brought on by a gallstone lodged within its lumen. The gallstone travels through a fistula that develops because of the constant pressure it exerts on the gall bladder. The symptoms are vague and confounding which can commonly lead to delay in diagnosis. The preferred imaging technique is a computed tomography scan. The diagnosis is confirmed by the identification of Rigler's Triad on a CT scan, which includes a small intestinal obstruction, pneumobilia, and an ectopic stone in the intestine. The condition is associated with several complications and needs to be treated with emergency surgery. This case demonstrates how a patient could have non-specific symptoms and how early detection by imaging was crucial to the patient's treatment.

The Diagnosis and Management of Recurrent Gallstone Ileus: A Case Report

Gallstone ileus is one of the rare and insidious causes of small bowel obstruction, which should always be kept in mind by clinicians, especially when encountering older people with a history of gallstones disease. The high mortality and morbidity rate associated with the condition can be mostly attributed to delayed or misdiagnosis. Imaging modalities, particularly CT scans, play an important role in correct and timely diagnosis. We present the case of a 65-year-old man with a two-year history of colicky biliary pain, who had severe abdominal pain with obstructive symptoms for five days before admission. The diagnosis of gallstone ileus is made using CT scan findings. Enterolithotomy alone was performed three days later. A second, smaller migrated gallstone was also found, which excreted spontaneously. After 20 days, the patient achieved full recovery and was discharged.

Gallstone ileus in a middle-aged male with an atypical history: a case report

Currently, gallstone ileus is an unusual complication of cholelithiasis (0.3–3.0 %) and a rare cause of mechanical bowel obstruction (0.1–4.0 %). The rarity of the condition makes it impossible to plan the large prospective randomized clinical trials, so the analysis of case reports is significant for decision making in the management of gallstone ileus. We report a case of gallstone ileus in a middle-aged male who had a history of surgery for duodenal ulcer perforation in past. A combination of peptic ulcer disease and cholelithiasis is based on a reduced gastrointestinal hormones secretion. Clinical specialists need to consider information about the greater frequency and asymptomatic clinical course of gallstone disease against a background of duodenal ulcer. Duodenal ulcer scar and bulbar deformity may promote to the cholecystoduodenal fistula formation. In the presence of an acute bowel obstruction symptoms and the absence of gallbladder instrumental examination results, it is possible to recommend the prior gastroduodenoscopy for the pre-operative pneumobilia detection. The optimal surgical approaches for acute gallstone ileus are still controversial.

Gallstone ileus: Unusual complication of cholelithiasis: A case report

Introduction and importance

Gallstone ileus is a rare cause of intestinal obstruction with a high morbidity and mortality rate, which is often linked to delayed or misdiagnosed intestinal obstruction. Gallstone ileus requires a high index of suspicion to diagnose.

Case presentation

This report describes a 55-year-old male who presented the case of gallstone ileus with four years history of gallstone disease, emergency explorative laparotomy was done, enterotomy and stone extraction from the small bowel, the post-operative patient was uneventful and was discharged after full enteral tolerance.

Clinical discussion

CT scanning has become increasingly important as a diagnostic tool, with a sensitivity of 93% and its use has increased in recent years, In the case of patients with gallstone ileus, simple enterolithotomy is both safe and effective.

Conclusions

Gallstone Ileus is an uncommon complication of gallstone disease, most commonly seen in females in advanced age, our case report presents young adult male and high index suspicion in diagnosis and urgent intervention is mandatory for better outcome of the patients.

•

Generally this condition is seen in female with advanced age, but this case, reports atypical presentation of the disease according patient age and gender.

•

Will raise awareness among patients who have a delayed presentation of the disease and acquire challenges associated to gallstones, such as gallstone illeus.

•

To illustrate all necessary requirement of diagnosis and management of disease. Including classic radiological features and relevant intra-operative images.

•

Summarize the surgical techniques performed to management gallstone ileus.

Conservative management of the colonic gallstone

A 74-year-old woman presents with a 7-day history of increasing lower abdominal pains and reduced bowel movements; resulting in absolute constipation.Twenty-four hours prior to admission she also had symptoms of nauseous and significant abdominal distention. Her past medical history included; diverticulitis, type 2 diabetes, hypercholesterolemia, an ultrasound scan in 2005 confirming gallstones, but no previous abdominal surgery.She was initially treated for bowel obstruction and a CT arranged. CT showed a 4.5 cm gallstone in mid-sigmoid colon and a cholecystocolonic fistula. She was booked for colonoscopy±laparotomy, but on the morning of her planned procedure she repeatedly opened her bowels. Subsequent colonoscopy was negative and repeat CT confirmed the stone was no longer within the gastrointestinal tract.

Surgical Treatment of Gallstone Ileus: Less Is More

<b><i>Introduction:</i></b> The objective of this study was to evaluate the need for cholecystectomy in patients who underwent surgery for gallstone ileus. <b><i>Methods:</i></b> This was a retrospective review of the clinical history of patients who underwent surgery for gallstone ileus between December 1992 and December 2018 and follow-up until October 2020. Data regarding the surgical intervention, location of the obstruction, and surgical procedure performed were collected, as well as complications in relation to biliary pathology in the postoperative period. <b><i>Results:</i></b> Twenty-five patients underwent surgery for gallstone ileus. In all patients, except one, the site of the obstruction was identified. The mean age of the patients was 72 (standard deviation [SD] 13.3) years, with a female predominance (18: 7). The patients presented symptoms, on average, 2.9 (1–7) days before going to the emergency room; the primary symptoms were vomiting associated with abdominal pain and constipation (56%). Fifty-six percent of patients were diagnosed preoperatively by imaging tests. In 72% of patients, an enterolithotomy was performed alone without any other intervention on the gallbladder or bile duct. Eighty-three percent of the patients did not present any cholecystobiliary complications during the entire follow-up period, and urgent or delayed cholecystectomy was not performed after the acute episode. <b><i>Conclusions:</i></b> Gallstone ileus is a rare entity, and there are no randomized studies that support a preferred treatment. If surgical intervention is required, enterotomy for stone extraction is a safe and effective technique, and in our experience, urgent or delayed cholecystectomy is not necessary.

Gallstone ileus: a rare type of intestinal obstruction in Ghana

Gallstone ileus is an uncommon cause of intestinal obstruction in Ghana. A patient with gallstone ileus that was diagnosed intra-operatively after being treated conservatively as adhesive small bowel obstruction for ten days is reported to highlight the importance of the clinical information in this condition. A 60-year-old Chinese male with recurrent intestinal obstruction who was initially being managed at a primary healthcare facility was subsequently referred to a tertiary hospital on account of computer tomography diagnosis of an intraluminal object obstructing the bowel. He had hypokalaemia that was corrected before surgery. Intra-operatively, a 4.5cm in diameter gallstone was removed from the terminal ileum. Gallstone ileus is rare in Ghana. A high index of suspicion is required to avoid a delay in diagnosis due to the low incidence of cholelithiasis in Ghana.

Funding

None declared.

Duodenal Obstruction Due to Giant Gallstone: A Case Report

Background

Duodenal obstruction due to a gallstone, also known as Bouveret’s syndrome, is one type of gallstone ileus. This is a rare complication of cholelithiasis. Among gallstone ileus cases, duodenal obstruction is alsorare. Apart from rareness, diagnosis is challenging due to unspecific clinical manifestation. Treatment options have benefits and drawbacks with each as well. Therefore, setting an appropriate option in a certain patient is an important issue.

Case Report

An 85-year-old woman presented clinically with a gastric outlet obstruction. Upper gastrointestinal (GI) endoscopy was attempted but endoscopic exploration was limited because of duodenum filled by fluid. Rigler’s triad was detected on abdominal enhanced CT scan: duodenal obstruction, ectopic gallstone within duodenum lumen, pneumobilia. The stone was very large (9 cm long). The diagnosis was duodenal obstruction due to giant gallstone and cholecysto-duodenum fistula. The patient was treated with a radical one-stage procedure: fistulotomy for gallstone removal, cholecystectomy, side-to-side Roux-en-Y duodenojejunostomy. There were no complications related to surgery during the follow-up period.

Conclusion

Surgery plays an important role in management of duodenal obstruction due to a gallstone, especially a large and impacted stone. Radical one-stage surgery is one of the feasible, safe, and efficient procedures in selected patients.

The curious case of biliary emesis and bowel obstruction from Bouveret syndrome

Bouveret syndrome is a rare complication of biliary lithiasis. This sequela is caused by the passage of the gallstone via a bilioenteric fistula, resulting in an impacted gallstone in the duodenum or stomach. The common presentation of non-specific symptoms contributes to the diagnostic uncertainty and delay, which is strongly associated with adverse outcomes. We report an uncomplicated stone extraction via open gastrotomy in an elderly man afflicted with bowel obstruction and biliary vomit secondary to Bouveret syndrome.

[Colonic gallstone ileus: a rare cause of colonic obstruction]

Bile ileus with migration of the gallstone into the colon through cholecystocolonic fistula is rare. The diagnosis is difficult and often late. We here report the case of a 89-year old patient with a history of sigmoid diverticular disease presenting with colonic obstruction associated with bile ileus caused by migration of a large gallstone through cholecystocolonic fistula. Abdominal CT scan allowed the diagnosis. The patient underwent surgical extraction of the gallstone with sigmoidotomy followed by sigmoidostomy with subsequent recovery of the digestive continuity. The cholecystocolonic fistula wasn't identified.

Abdominal Hernias, Giant Colon Diverticulum, GIST, Intestinal Pneumatosis, Colon Ischemia, Cold Intussusception, Gallstone Ileus, and Foreign Bodies: Our Experience and Literature Review of Incidental Gastrointestinal MDCT Findings

Incidental gastrointestinal findings are commonly detected on MDCT exams performed for various medical indications. This review describes the radiological MDCT spectrum of appearances already present in the past literature and in today's experience of several gastrointestinal acute conditions such as abdominal hernia, giant colon diverticulum, GIST, intestinal pneumatosis, colon ischemia, cold intussusception, gallstone ileus, and foreign bodies which can require medical and surgical intervention or clinical follow-up. The clinical presentation of this illness is frequently nonspecific: abdominal pain, distension, nausea, fever, rectal bleeding, vomiting, constipation, or a palpable mass, depending on the disease. A proper differential diagnosis is essential in the assessment of treatment and in this case MDCT exam plays a central rule. We wish that this article will familiarize the radiologist in the diagnosis of this kind of incidental MDCT findings for better orientation of the therapy.

Gallstone ileus: An overview of the literature

INTRODUCTION

Gallstone ileus represents 4% of the causes of bowel obstruction in the general population, but increases to 25% in patients above the age of 65 years. Gallstone ileus does not present with unique symptoms, making diagnosis difficult. Its management is surgical, but there is no consensus as to which of the different surgical techniques is the procedure of choice. At present, there is no recent review of this pathology.

AIM

To conduct an up-to-date review of this disease.

MATERIALS AND METHODS

Articles published within the time frame of 2000 to 2014 were found utilizing the PUBMED, EMBASE, and Cochrane Library search engines with the terms "gallstone ileus" plus "review" and the following filters: "review", "full text", and "humans".

RESULTS

The results of this review showed that gallstone ileus etiology was due to intestinal obstruction from a gallstone that migrated into the intestinal lumen through a bilioenteric fistula. The presence of 2 of the 3 Rigler's triad signs was considered diagnostic. Abdominal tomography was the imaging study of choice for gallstone ileus diagnosis and the surgical procedures for management were enterolithotomy, one-stage surgery, and two-stage surgery. Enterolithotomy had lower morbidity and mortality than the other 2 procedures.

CONCLUSIONS

The aim of gallstone ileus treatment is to release the obstruction, which is done through enterolithotomy. It is the recommended technique for gallstone ileus management because of its lower morbidity and mortality, compared with the other techniques.

Laparoscopic Management of a Proximal Jejunal Gallstone Ileus with Patulous Ampulla and Choledochal Cyst-a Report of Unusual Presentation and a Review

Gallstone ileus is a diagnosis of rarity, and a proximal site of obstruction in a young patient is even rare. Of the three cases in our experience, we found two cases of gallstone ileus (GSI) with typical epidemiology and presentation, one had combination of multiple rare associations. We report such a case, suspected to have gallstone ileus on ultrasound and confirmed diagnosis on computed tomography. Presence of biliary-enteric fistula, old age, and obstructive features, as in typical cases, was a bigger asset for diagnosis, but it was difficult to entertain diagnosis of GSI in young girl in absence of a demonstrable biliary-enteric fistula, with uncommon association of choledochal cyst and sickle cell disease. A very surprising finding, dilated major papilla, could however explain the pathogenesis which has also been reported in the past. Although differential opinions regarding management exist, we decided to follow two-stage surgery as our institute protocol. A minimal access approach has been immensely helpful in accurate diagnosis, and expedative management with early recovery has been proven in the past studies which we agreed with our experience.

Novel treatment options for Bouveret's syndrome: a comprehensive review of 61 cases of successful endoscopic treatment

In Bouveret's syndrome, a biliary stone obstructs the duodenum. Surgical treatment is plagued by high morbidity and mortality. Therefore, endoscopic treatment has become a first-line approach. Areas covered: A literature search of Medline and Google Scholar databases was performed using the terms endoscopic treatment, non-operative treatment, Bouveret's syndrome, and gallstone ileus. Sixty-one cases of successful endoscopic treatment were found over the period 1978-2016 and are summarized herein. Therapeutic modalities used in 52 patients with complete success included mechanical lithotripsy (40% of cases), electrohydraulic lithotripsy (21% of cases), extraction of the intact stone and laser lithotripsy (15% of cases each), extracorporeal shockwave lithotripsy and duodenal stenting (4% of cases each). In the remaining 9 patients, stone fragments migrated distally and required surgical removal. Cholecystectomy was performed in five (8.2%) of 61 patients and gallbladder cancer was detected in three (4.9%) patients. Expert commentary: Meticulous preparation, including that of instruments, personnel, patient anesthesia, and X-ray availability, is key to success in this unusual situation. Partial success (stone fragmentation and mobilization to another location) may render surgery easier as these patients present with dense adherences in the right upper quadrant. Cholecystectomy is reserved for highly selected patients (e.g. relapsing ileus, gallbladder cancer).

[Colonic gallstone ileus: A rare cause of intestinal obstruction]

BACKGROUND

A gallstone colonic ileus is a very rare condition.

CLINICAL CASE

The case is reported of an 87 year-old patient who came to the Emergency Department due to an intestinal obstruction of several days onset, which was caused by a gallstone affected sigmoid colon.

CONCLUSION

Colonic gallstone ileus is a rare disease that usually occurs in older patients due to the passage of large gallstone directly from the gallbladder to colon, through a cholecystocolonic fistula. It has a high morbidity and mortality.

Gallstone ileus with choledochoduodenal fistulas: A case report and literature review

Gallstone ileus (GI) with choledochoduodenal fistulas and multiple sites of intestinal obstruction are uncommon. Early diagnosis and appropriate surgery are crucial to reduce morbidity and mortality of GI. Computed tomography plays an important role in making early, accurate diagnosis, and laparoscopy-assisted surgery is helpful to optimizing surgical treatment and early recovery. This paper presents such a case and performed a literature review to improve the awareness of the approach for the management of GI.

Karewsky syndrome: A case report and review of the literature

INTRODUCTION

Gallstone ileus can be a lethal disease, rarely suspected in the clinical scenario. It represents about 25% of all bowel obstruction cases in patients older than 65. There is a classification of gallstone ileus based on the onset time: acute, subacute and chronic (Karewsky syndrome). We describe the first reported case of chronic gallstone ileus.

CASE PRESENTATION

A 78-year-old female was admitted to the ER with a 15-day case of consistent bowel obstruction. The subject reported a five-year history of recurrent hospital admissions that resolved spontaneously after non-surgical management. Karewsky syndrome was diagnosed and managed with enterolithotomy. After five days of postoperative evolution the patient was discharged, and at six months follow up, no other hospital admission or relapse has been registered.

DISCUSSION

The gallstone ileus diagnosis demands a higher clinical suspicion, there is no biochemical marker, and an abdominal CT is ideal for imaging-based diagnosis. There is no consensus on the optimal surgical approach.

CONCLUSION

We describe the first case of Karewsky syndrome and a gastro-jejune and gastric-choledochus double fistula. We emphasize the importance of higher clinical suspicion for patients with bowel obstruction older than 65 years old and make evident that although there are not evidence-based guidelines for this treatment, enterolithotomy is a recommended approach.

Gallstone ileus treated with non-surgical conservative methods: a case report

Introduction

The preoperative diagnosis of gallstone ileus is challenging due to the variability of its presentation, often resulting in late diagnosis. Controversy remains regarding the management of gallstone ileus; surgery is the standard treatment, but also less invasive approaches have proven to be successful. We present an unusual case of gallstone ileus and its conservative treatment.

Case presentation

We describe the case of a 49-year-old Caucasian woman with a bowel sub-occlusion, treated conservatively. The imaging technique (plain abdominal X-ray and computed tomography scan) led to a diagnosis of gallstones ileus. A surgical intervention was not performed. Instead, she underwent extracorporeal shock-wave lithotripsy to fragment the stones, mechanical intestinal dilatation for ileocolic stenosis and endoscopic removal of the gallstone. The presence of an apricot shell contributed to the bowel occlusion and was removed. The intervention was successful and without complications.

Conclusions

Given the variability of the gallstone ileus presentation, surgery could not be the only treatment for our patient. In our case report, we show that colonoscopy could be a non-invasive approach that allows for diagnosis and treatment at the same time. The available data do not show a higher rate of recurrent biliary disease in cases where this method has been used, therefore in select patients, a conservative treatment could be an effective solution.

Perforated closed-loop obstruction secondary to gallstone ileus of the transverse colon: a rare entity

Introduction. Gallstone ileus (GSI) of the colon is an extremely rare entity with potentially serious complications including perforation. Case Presentation. An 88-year-old man presented to the emergency department with abdominal pain and distension. Clinical exam revealed signs of peritonism. Computed tomography (CT) revealed GSI of the transverse colon with a closed-loop large bowel obstruction (LBO) and caecal perforation. The patient underwent emergency laparotomy. A right hemicolectomy was performed, the gallstone was removed, and a primary bowel anastomosis was undertaken. A Foley catheter was sutured into the residual gallbladder bed to create a controlled biliary fistula. The patient recovered well postoperatively with no complications. He was discharged home with the Foley catheter in situ. Discussion. Gallstone ileus is a difficult diagnosis both clinically and radiologically with only 50% of cases being diagnosed preoperatively. Most commonly it is associated with impaction at the ileocaecal valve and small bowel obstruction. Gallstone ileus should also be considered as a rare but potential cause of LBO. This is the first reported case of caecal perforation secondary to gallstone ileus of the transverse colon. Successful operative management consisted of a one-stage procedure with right hemicolectomy and formation of a controlled biliary fistula.

Gastric outlet obstruction in a patient with Bouveret's syndrome: a case report

Background

Gallstone ileus accounts for 1% to 4% of cases of mechanical bowel obstruction, but may be responsible for up to 25% of cases in older age groups. In non-iatrogenic cases, gallstone migration occurs after formation of a biliary-enteric fistula. In fewer than 10% of patients with gallstone ileus, the impacted gallstones are located in the pylorus or duodenum, resulting in gastric outlet obstruction, known as Bouveret’s syndrome.

Case presentation

We report an 86-year-old female who was admitted to hospital with a 10-day history of persistent vomiting and prostration. She was in hypovolemic shock at the time of arrival in the emergency department. Investigations revealed a gallstone in the duodenal bulb and a cholecystoduodenal fistula. She underwent surgical gastrolithotomy. Unfortunately, she died of aspiration pneumonia on the fourth postoperative day.

Conclusion

This case shows the importance of considering Bouveret’s syndrome in the differential diagnosis of gastric outlet obstruction, especially in the elderly, even in patients with no previous history of gallbladder disease.

Resolution of gallstone ileus with spontaneous evacuation of gallstone: a case report

Gallstone ileus is an infrequent complication of cholelithiasis. The formation of a fistula between the gallbladder and duodenum may allow a gallstone to enter the gastrointestinal (GI) tract. Gallstone ileus generally occurs in the elderly patients and is associated with significant mortality. Spontaneous resolution of gallstone ileus after passage of gallstone per rectally, though rare, has been reported Farooq et al. (Emerg Radiol 4(6):421-423, 2007). We describe a 60-year-old woman who presented with a 3-day history of vomiting, pain, distension and constipation .Radiological investigations revealed dilatation of small bowel loops with multiple air fluid levels with a large lamellated radio-opaque density measuring 4.4 cm × 4 cm seen in the right iliac fossa. A possibility of gallstone ileus was kept. Because of co-morbid conditions (post-myocardial infarct with cardiac failure), surgery could not be done and patient was kept on conservative management. Three days later patient had sudden relief of her symptoms after passing a large calculus per rectally suggesting a spontaneous evacuation of gallstone. This case highlights the possibility of spontaneous resolution of gallstone ileus after the passage of gallstone. It has been reported in stones less than 2.5 cm. However, to the best of our knowledge, this is the first time in which a large stone measuring 4 cm × 3.8 cm passed spontaneously.

Gallstone ileus after laparoscopic cholecystectomy

Gallstone ileus represents a rare complication (0,3-0,5%) of a serious, but common disease-gallstones, which affect around 10% of the population in the USA and Western Europe. Associated diseases (usually severe), elderly patients, delayed diagnosis and therapy due to late presentation to the hospital, account for the morbidity and mortality rates described in literature. We present the case of a patient with partial colon obstruction due to a large gallstone that was "lost" during an emergency laparoscopic cholecystectomy. The calculus eroded the intestinal wall, partially occluding the lumen, triggering recurrent Kerwsky-like, subocclusive episodes. The intraperitoneal abscess has spontaneously drained through the subhepatic drain and once the tube has been removed, a persistent intermittent fistula became obvious.

An unusual cause of a non-functioning stoma in an 87-year-old gentleman

Gallstone ileus is a rare but significant cause of intestinal obstruction particularly among the elderly population. Symptoms are often vague and therefore a high suspicious index is required for successful diagnosis. In this report, we present the case of an 87-year-old gentleman with a background history of cholelithiasis and ileostomy for ulcerative colitis who was admitted with a 24-h history of his stoma not functioning. He had an abdominal x-ray and CT which were consistent with small bowel obstruction with no identifiable cause. He underwent an examination of his stoma under general anaesthesia which revealed a 2.5 cm gallstone wedged several centimetres near the entry point of the stoma. The purpose of this report is to highlight the importance of considering gallstones as a potential cause of a non-functioning stoma in any patient with a significant history of cholelithiasis.

An unforgettable concurrence: Successfully managed gallstone ileus accompanied by diabetic nephropathy

BACKGROUND

Gallstone ileus is an uncommon complication of gall stones associated with potentially serious morbidity and mortality.

CASE REPORT

We reported a 60-year-old male case who presented with renal failure and pain in right hypochondriac region. He also had a history of brain infarcts along with diabetes which is an additional factor for mortality. On Computed Tomography of the abdomen, he was diagnosed to have cholecystocholedochal fistula including air in the gall bladder and obstruction in the distal part of the ileum. Computed tomography plays an important role to make the proper diagnosis and in treatment.

CONCLUSIONS

As in our case, diagnosis was challengeable because of renal failure,diabetes, septicaemia and intestinal obstruction (peritonitis). We did surgery on the basis of peritonitis which remains the only choice in such cases. In follow- up of 1 month patient was doing well and asymptomatic.

Gallstone ileus--clinical and therapeutic aspects

Gallstone ileus represents a rare (0.3-0.5%), but serious complication of a common illness--the gallbladder lithiasis and the incidence of this fascinating disease has remained the same over the years. The main actual characteristics of this pathology are the age over 65, the female gender (men/women ratio 1/5:1:10--due to the high rate of vesicular lithiasis) and the under 50% diagnostic established preoperatively. The frequency of gallstone ileus recurrence is of 4,7-5%. In this article, we discuss the pathogenesis of this illness presenting all the mechanisms described in the medical literature. The Rigler triad found at the abdominal CT-scan generally established the diagnosis. Still, in 25% of the cases we have a misdiagnosis because of the underestimation of the size of the gallstone. Finally, the treatment of gallstone ileus has had major changes from the past. We described the endoscopic and laparoscopic approach, which represents the modern treatment of this disease. Despite these diagnostic and therapeutic possibilities, the mortality remains high and the common causes are associated comorbidities and late presentation to the physician.

Gallstone ileus of the sigmoid colon: an unusual cause of large-bowel obstruction

Gallstone ileus of the colon is an exceedingly rare cause of large-bowel obstruction. It is usually the result of fistula formation between the gallbladder and large bowel facilitating entry of the stone into gastrointestinal tract. Contrast enhanced abdominal computed tomography is an important diagnostic aid. Surgical management is the treatment of choice to prevent the disastrous complications of large-bowel obstruction. We describe the case of a 92-year-old man who presented with symptoms and signs of large-bowel obstruction. Radiological investigation showed a large gallstone impacted in the sigmoid colon. Open enterolithotomy was undertaken relieving the obstruction and the patient made a full recovery.

Gallstone obstructive ileus 3 years post-cholecystectomy to a patient with an old ileoileal anastomosis

The present case is one of gallstone obstructive ileus due to gallstones 3 yr after laparoscopic cholecystectomy. It is interesting because of the sex of the patient, the fact that ileus occurred 3 yr after cholecystectomy and that the localization of the obstruction was an old side-to-side ileoileal anastomosis due to a diverticulectomy following intussusception of Meckels' diverticulum at the age of 3.

A case of gallstone-induced small bowel necrosis masquerading as clinical appendicitis

Cholecysto-duodenal fistula and gallstone ileus are well-recognised complications of gallstone disease. However, small bowel necrosis is a rare complication of gallstone disease. We describe a case of gallstone-induced ileal necrosis presenting with symptoms and signs resembling acute appendicitis. A 79-year-old woman presented to the surgical team with central abdominal pain which subsequently shifted to the right iliac fossa. Clinically, the patient had localised perotinism in the right iliac fossa with high inflammatory markers. Abdominal radiography showed no diagnostic features. Initial clinical impression was that of acute appendicitis. Given that this diagnosis was unlikely in a patient of this age, an abdominal CT scan was performed. The CT scan showed evidence of a large gallstone causing small bowel obstruction in the presence of a cholecysto-duodenal fistula. At surgery, she was found to have an area of necrosis with a pin-point perforation at the site of impaction of the gallstone in the proximal ileum. This occurred secondarily to pressure necrosis from the gallstone impacting at a site where the small bowel diameter narrows in transition from jejunum to ileum. A limited small bowel resection was performed with an uncomplicated postoperative course. This case report draws attention to a rare complication of gallstone disease which presents with a clinical picture similar to acute appendicitis. Preoperative investigation for an elderly patient who presents with an acute abdomen should include an abdominal CT scan to diagnose any rare disease processes which otherwise may not be suspected.

Jejunal gallstone ileus: an unusual site of gallstone impaction

INTRODUCTION

Gallstone ileus is a life-threatening surgical emergency where characteristic imaging can be diagnostic. Jejunum is the one of the rare sites of gallstone impaction.

MATERIALS AND METHODS

We hereby emphasize the role of multidetector computed tomography (MDCT) by describing a case of jejunal gallstone ileus with cholecystoduodenal fistula in a 59-year-old lady who presented with symptoms and signs of proximal small bowel obstruction.

CONCLUSION

MDCT of the abdomen established the diagnosis, and the patient managed surgically.