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

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.

Developments in the Diagnosis and Management of Cholecystoenteric Fistula

Background: Cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis. CEF refers to one or more pathological perforations between the gallbladder and the adjacent gastrointestinal tract, first described by Bartholin in 1645. The aim of this review is to examine the etiology, symptoms, diagnosis, and treatment of CEF.Methods: A literature search was conducted according to a set of criteria in PubMed for historical and current peer-reviewed studies regarding CEF.Results: Clinical manifestations of CEF are always latent. Despite modern imaging studies and diagnostic methods, it is still very difficult to definitively diagnose CEF preoperatively. Instead, CEF is often accidentally discovered in the perioperative period or via intraoperative exploration.Conclusions: Without appropriate preoperative preparation, gastrointestinal injury and intraoperative bleeding often occur. CEF often goes unreported, and its diagnosis and treatment are still controversial. Early diagnosis of CEF is essential for effective treatment and improved outcome.

Bouveret syndrome: a clinicoradiological perspective

An 87-year-old woman presented to us with a 5-day history of worsening epigastric pain and vomiting. Her medical history included known gallstones and a previous episode of acute cholecystitis complicated by a perforated gallbladder for which she had declined surgery 5 years prior. Radiological imaging confirmed a large gallstone impacted in the first part of the duodenum with gross gastric outlet obstruction and pneumobilia, confirming the diagnosis of Bouveret syndrome, an often overlooked and rare variant of gallstone ileus. Following an unsuccessful oesophagogastroduodenoscopy for stone retrieval, she underwent a laparotomy and gastrotomy with a successful outcome and discharged from hospital 4 weeks following the procedure.

Bouveret Syndrome: A Systematic Review of Endoscopic Therapy and a Novel Predictive Tool to Aid in Management

BACKGROUND AND GOALS

Bouveret syndrome is characterized by gastroduodenal obstruction caused by an impacted gallstone. Current literature recommends endoscopic therapy as the first line of intervention despite significantly lower success rates compared with surgery. The lack of treatment efficacy studies and the paucity of clinical guidelines contribute to current practices being arbitrary. The aim of this systematic review was to identify factors that predict outcomes of endoscopic therapy. Subsequently, a predictive tool was devised to predict the success of endoscopic therapy and recommendations were proposed to improve current management strategies of impacted gallstones in the upper gastrointestinal tract.

METHODS

A systematic search of PubMed, Medline, Cochrane, and Scopus was performed for articles that contained the terms "Bouveret syndrome," "Bouveret's syndrome," "gallstone" AND "gastric obstruction" and "gallstone" AND "duodenal obstruction" that were published between January 1, 1950 to April 15, 2018. Articles were reviewed by 3 reviewers and raw data collated. χ and Kolmogorov-Smirnov tests were used to test associations between predictors and endoscopic outcomes. A logistic regression model was then used to create a predictive tool which was cross validated.

RESULTS

Failure of endoscopic therapy is associated with increasing gallstone length (P<0.0001) and impaction in the distal duodenum (P<0.05). Using multiple endoscopic modalities is associated with better success rates (P<0.05). The novel predictive tool predicted success of endoscopic therapy with an area under the receiver operating characteristic score of 0.86 (95% confidence interval: 0.79-0.94).

CONCLUSION

In Bouveret syndrome, a selective approach to endoscopic therapy can expedite definitive treatment and improve current management strategies.

Laparoscopic and endoscopic cooperative surgery for cholecystogastric fistula: A case report

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Cholecystogastric fistula (CGF) is rarest form of cholecystoenteric fistula (CEF).

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Our patient had a CGF close to the pylorus.

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Laparoscopic and endoscopic cooperative surgery (LECS) was used to treat CGF.

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Intraoperative endoscopy helped see the margin between fistula suture and pylorus.

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LECS is a viable option to treat CGF, a rare CEF in biliary tract surgery.

Introduction

Cholecystoenteric fistula (CEF) is rare in biliary tract surgery, and cholecystogastric fistula (CGF) is the rarest form of CEF. Although open cholecystectomy with the closure of the fistula is the gold standard treatment for nonobstructing biliary-enteric fistulas, the optimal treatment for CGF has not been established. Laparoscopic and endoscopic cooperative surgery (LECS), a minimally invasive surgery for gastric submucosal tumors, reportedly helps achieve favorable postoperative outcomes. This report presents a case wherein CGF was treated with LECS.

Case presentation

An-84-year-old man with a history of chemotherapy for ileocecal diffuse large B cell lymphoma presented with fever and abdominal pain. He was diagnosed with cholangitis, and endoscopic lithotripsy was performed. Abdominal contrast-enhanced computed tomography revealed gastric wall thickening close to the gallbladder, indicating a malignant lymphoma. Esophagogastroduodenoscopy revealed a concavity on the anterior wall of the antrum of the stomach. Direct endoscopic cholangiography, which was performed by the injection of a contrast medium into the concavity, confirmed the concavity to be a CGF. Cholecystectomy with the closure of the fistula using the LECS was performed to check for suture line leakage and the positional relation of the suture line and the pylorus. The resected specimen showed acute and chronic cholecystitis without malignancy. The patient did not experience postoperative complications in the subsequent 3 months.

Discussion

Resection and closure of the fistula using LECS were performed successfully.

Conclusion

LECS can be performed for CGF. LECS enables intraoperative observation of the fistula and suture line, and thus reduces postoperative complications.

Cholecystoduodenal fistula, an infrequent complication of cholelithiasis: Our experience in its surgical management

INTRODUCTION

Bilioenteric fistulas are the abnormal communication between the bile duct system and the gastrointestinal tract that occurs spontaneously and is a rare complication of an untreated gallstone in the majority of cases. These fistulas can cause diverse clinical consequences and in some cases be life-threatening to the patient.

AIM

To identify the incidence of bilioenteric fistula in patients with gallstones, its clinical presentation, diagnosis through imaging study, surgical management, postoperative complications, and follow-up.

MATERIALS AND METHODS

A retrospective study was conducted to search for bilioenteric fistula in patients that underwent cholecystectomy at our hospital center due to cholelithiasis, cholecystitis, or cholangitis, within a 3-year time frame.

RESULTS

Four patients, 2 men and 2 women, were identified with cholecystoduodenal fistula. Their mean age was 81.5 years. Two of the patients presented with acute cholangitis and 2 presented with bowel obstruction due to gallstone ileus. All the patients underwent surgical treatment and the diagnostic and therapeutic management of each of them was analyzed.

CONCLUSIONS

The incidence of cholecystoduodenal fistula was similar to that reported in the medical literature. It is a rare complication of gallstones and its diagnosis is difficult due to its nonspecific symptomatology. It should be contemplated in elderly patients that have a contracted gallbladder with numerous adhesions.

Uncommon presentation of a common disease - Bouveret's syndrome: A case report and systematic literature review

AIM

To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).

METHODS

A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.

RESULTS

A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.

CONCLUSION

There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.

[Gastrointestinal bleeding and delirium, challenges in the diagnosis of gallstone ileus: A case report and review of literature]

BACKGROUND

Gallstone ileus is a non-strangulated mechanical obstruction of the small bowel or colon as a result of the passage of gallstones through a biliary enteric fistula. It is a rare complication of cholelithiasis, affects patients over 65 years, and the disease occurs predominantly in females. Preoperative diagnosis is difficult due to the lack of specific signs and symptoms in elderly patients with multiple comorbidities.

CLINICAL CASE

A 93-year-old female presenting with a one-week history of upper gastrointestinal bleeding, electrolyte imbalance and community- acquired pneumonia pneumonia. During her prolonged hospital stay she presented an intestinal obstruction. The diagnosis of gallstone ileus was made by CT scan. Despite surgical treatment, she died due to late diagnosis.

CONCLUSIONS

Gallstone ileus is a rare pathology, difficulty in diagnosis prolongs hospital stay, which directly influences mortality.