Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Ann Surg. 2014;259:329-335. [PMID: 23295322 DOI: 10.1097/sla.0b013e31827eefed]

Clinical outcome of gallstone ileus; a single-centre experience of case series and review of the literature

BACKGROUND

Gallstone ileus (GI) is a rare entity which is seen in 0.5% of patients with cholelithiasis. In this study, we aimed to share our clinical approach to GI, to present our long-term results and to draw clinicians' attention to this rare entity.

MATERIALS AND METHODS

This study included 11 patients with GI whose medical records were evaluated retrospectively.

RESULTS

Majority of the 11 patients were female (63.7%, n:7) and the mean age was 71.9 ± 14.10 (range: 50-91). Most common presenting complaints were vomiting (n: 9) and abdominal pain (n: 9). The mean interval from the onset of symptoms to the hospital admission was 3.8 ± 0.75 (range 3-5) days. Rigler triad in abdominal computed tomography (CT) was detected in all cases. Enterolithotomy, one-step procedure and conservative treatment were performed in five (45.4%), four (36.3%) and two (18.1%) patients, respectively. Enterolithotomy group was found to have higher risk according to American Society of Anesthesiologists (ASA) classification, shorter operation time and less intraoperative blood loss.

CONCLUSION

Although enterolithotomy is the first choice for patients with GI, one-step procedure should be kept in mind as a more advantageous technique in low-risk patients.

Gallstone Ileus in Octogenarians: Is Cholecystectomy Really Needed?

Gallstone ileus is an uncommon complication of cholelithiasis and occurs when a gallstone migrates through a cholecystoenteric fistula and impacts within the gastrointestinal tract. Surgical intervention remains the treatment of choice, which consists of a full-thickness incision of the visceral wall and removal of the impacted gallstone. In this paper we present the treatment approach of 6 cases of gallstone ileus in octogenarians. In our cohort, intestinal obstruction was resolved through an enterotomy or gastrotomy and lithotomy/stone extraction in every patient. No cholecystectomies were undertaken. Despite the fact that gallstone ileus is diagnosed in small percent of patients suffering from gallstone disease, it accounts for a large proportion of intestine obstruction in patients older than 65 years old. Since accurate diagnosis and timely intervention are vital, providers should be familiar with the diagnostic approach and the treatment of this clinical entity.

Colonic Gallstone Ileus: Treatment Challenges

Intestinal obstruction at the level of the colon is rarely caused by a gallstone. Colonic gallstone is more frequently observed in elderly patients and is associated with high mortality due to treatment challenges. Management with less invasive approaches, including mechanical lithotripsy and endoscopy has been evolving. However, the outcomes are variable, and surgery remains the main cornerstone of treatment. We present a case of an 89-year-old male with gallstone ileus at the level of the sigmoid colon in whom treatment with endoscopy was not successful. We performed an extensive review of the literature to understand the most common presentation, diagnostic modalities, and treatment approach of the sporadic reported cases of colonic gallstone ileus.

Totally laparoscopic resolution of gallstone ileus: A case report

INTRODUCTION

Gallstone ileus is an uncommon complication of long-term cholelithiasis. Emergent operations for gallstone ileus are associated with high postoperative morbidity. When feasible, the minimally invasive approach might help to improve the postoperative outcomes.

PRESENTATION OF CASE

A 63-year-old female was admitted for abdominal pain and vomiting. Computed tomography (CT) scan showed a cholecystoduodenal fistula and a 5 × 3 cm gallstone in the jejunum causing obstruction. An emergent laparoscopy was performed, and a gallstone was found inside the jejunum 40 cm distal to the ligament of Treitz. The 5 cm gallstone was extracted through an antimesenteric enterotomy. The jejunum was then closed transversally using interrupted sutures. The postoperative course was uneventful, and the patient was discharged on postoperative day 3.

DISCUSSION

Surgery is the mainstream treatment for gallstone ileus. Multiple operations and surgical approaches have been described: enterolithotomy (EL), one-stage surgery (EL, cholecystectomy, and fistula closure), bowel resection, and two-stage surgery (EL and delayed cholecystectomy with fistula closure). The choice of the procedure depends on the patient's characteristics, comorbidities, and experience of the surgical team.

CONCLUSION

In the emergency setting, a simple enterolithotomy with primary closure seems to be the optimal approach to solve the intestinal obstruction with low postoperative morbidity. The laparoscopic approach to gallstone ileus results in additional benefits for patients' recovery.

The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Cholecystoduodenal Fistula

Large gallstones could erode through gallbladder wall to nearby structures, causing fistulas, gastric outlet obstruction and gallstone ileus. They typically occur in elderly patients with comorbidities carrying therapeutic challenges. We present a case of a middle-aged woman who was thought to have symptomatic cholelithiasis. Extensive adhesions precluded safe cholecystectomy. While hepatobiliary iminodiacetic acid scan and magnetic resonance imaging with cholangiopancreatography (MRI-MRCP) failed to visualize the gallbladder, computed tomography (CT) was consistent with cholecystoduodenal fistula. A very large gallstone was seen endoscopically in the duodenum, which was broken down into pieces using a large stiff snare.

The Regularity of the Site of Impaction in Recurrent Gallstone Ileus: A Systematic Review and Meta-Analysis of Reported Cases

Objective

Due to the rarity of recurrent gallstone ileus (RGSI), its epidemiological and clinical features are elusive. With a focus on mortality and the site of impaction, this study consolidates the key clinical characteristics of index GSI (IGSI) and RGSI.

Methods

A meta-analysis of cases reported on RGSI was performed. Risk factors for mortality and site of impaction were examined, and a subgroup analysis was performed for age, sex, and site of impaction (jejunum, ileum, or others).

Results

In the final analysis, 50 (56 individual cases) studies were included. The paired data for the site of impaction was available for 45 patients. Women accounted for 87.3% of all RGSI cases included in the pooled analysis. The median age (interquartile range, IQR) of the patients was 70 (63-76) years, and the median time of recurrence (IQR) was 20.5 (8.5-95.5) days. The overall mortality rate was 11.8%, without correlation between the mortality rate and age, the time of recurrence, or the site of impaction. The region in which the stone was found in RGSI and IGSI was similar in most cases (p=0.002). Logistic regression also revealed a higher probability of stone impaction in the ileum in RGSI if it was the site of impaction in IGSI. In most cases, enterolithotomy was the preferred method.

Conclusions

A high index of suspicion for RGSI should be maintained for older women with a history of GSI. The region where the stone was impacted during IGSI should be investigated first in such patients.

Gallstone ileus: An unusual cause of intestinal obstruction

Gallstone ileus is an infrequent cause of intestinal obstruction. It is typically the result of cholecystoduodenal fistula, computed tomography scan is the best modality for the diagnosis. Surgical removal of the gallstone is the pillar of treatment to relieve intestinal obstruction. We report the case of a 77-year-old male with features of a small bowel obstruction. Computed tomography scan of the abdomen showed pneumobilia, a cholecystoduodenal fistula, and small bowel obstruction features suspicious for gallstone ileus. The patient had a laparotomy and removal of two gallstones via an enterotomy without postoperative complications.

Case report: Closed-loop bowel obstruction secondary to a double gallstone ileus

Introduction and importance

In this paper, we report an unusual case of a closed-loop bowel obstruction secondary to a double gallstone ileus. This type of pathology constitutes an emergency, and requires prompt surgical intervention to prevent further complications.

Presentation of case

The patient was a 90-year-old female who came to our emergency room with a clinical picture compatible with an acute abdomen. Imaging tests performed included a plain radiograph and abdominal CT-scan, which confirmed the diagnosis. The patient was then transferred to the operating room, and an open double enterolithotomy was performed, extracting two cylindrical gallstones with a diameter of over 2.5 cm. No treatment was given for either the gallbladder nor the biliary-enteric fistula due to the patient's physical status.

Clinical discussion

Gallstone ileus is a rare entity, but must be taken into consideration when a patient with an abdominal obstruction arrives to the emergency department, especially when signs such as pneumobilia or visualization of the stones are detected by imaging tests. Early surgical intervention is required to avoid complications. However, addressing the biliary-enteric fistula at the same time is a sensitive procedure that may not be advisable, depending on the status of the patient. This report includes a bibliographic review of existing cases of gallstone ileus and the specifics of its diagnosis and management.

Conclusion

This pathology can lead to serious complications if not managed properly. Prompt diagnosis and surgical intervention are essential to avoid complications such as intestinal gangrene and perforation. Inspecting the entire intestine during surgery is crucial for removing any additional gallstones that may be present to prevent the reappearance of symptoms.

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Gallstone ileus is an uncommon condition which requires an emergency surgical approach.

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The entire intestine should be inspected during surgery.

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A prompt diagnosis can be achieved via CT-scan.

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Management of gallbladder and biliary-enteric fistula is controversial.

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Enterolithotomy is the procedure of choice for relieving intestinal obstruction.

Beyond acute cholecystitis-gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

Neglected Gallstone Disease Presented As Gallstone Ileus: A Rare Cause of Intestinal Obstruction

Gallstone ileus is a rare complication of cholelithiasis seen in patients with a long history of cholelithiasis. It occurs more in the older age group and in the female gender. These patients have poor general condition and therefore selection of appropriate treatment is difficult. The clinician has to make a decision between immediate one-stage or two-stage closure of the cholecysto-intestinal fistula or waiting for natural closure. We have discussed the management of a rare cause of small bowel obstruction due to complication of untreated cholelithiasis.

A Restless Stone

Gallstone ileus is an infrequent cause of mechanical small bowel obstruction. The mortality rate of gallstone ileus remains relatively high, since gallstone ileus usually presents on elderly patients with multiple underlying diseases. Typically, the way of gallstone migration to small bowel is through biliary-enteric flstula, which is a rare complication of chronic cholecystitis. Patients present with diffuse abdominal pain and vomiting when the gallstone lodges in distal small bowel. The goals of surgical intervention include release of the bowel obstruction and closure of biliary-enteric flstula.

Gallstone ileus associated with cholecystogastric fistula: Case report, diagnosis and surgical treatment

Introduction

Gallstone Ileus is a rare complication of cholelithiasis, associated with multiple episodes of cholecystitis, with the formation of adhesions and fistulas between the gallbladder and adjacent organs. Its diagnosis is difficult, requiring complementary imaging tests such as computed tomography or radiography.

Presentation of case

Female patient, with intestinal obstruction for 7 days, associated with abdominal pain and previous episodes of pain in the right hypochondrium for 3 months. Abdominal CT scan identified aerobilia, gallstone impacted in the ileocecal valve and small loop dilatation, in addition to a probable cholecystogastric fistula. Opted for exploratory laparotomy, enterolithotomy and fistula correction in one surgical time.

Discussion

Gallstone ileus is rare among the complications of cholelithiasis, in addition to the fact that cholecystogastric fistula is associated with gastric pylorus obstruction and not impaction on the ileocecal valve. Imaging tests are useful to complement the diagnosis, and if Rigler's triad is present, the suspicion of gallstone ileus is increased. The presence of fistula between the gallbladder and stomach presents a frequency between 0 and 13.3%. There is no gold standard treatment for gallstone ileus, but surgery options for each type of patient and severity level.

Conclusion

There is no definitive protocol for optimal surgical treatment for biliary ileus, but the possibility of enterolithotomy associated with cholecystectomy and fistula correction can be evaluated in selected patients.

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Gallstone ileus is a rare cause of intestinal obstruction.

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Cholecystogastric fistula may be associated with ileum obstruction.

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One-step surgical treatment can be used in specific patients

Small Bowel Obstruction

Small bowel obstruction (SBO) remains a common problem for surgeons and nonsurgeons alike. Management of SBO has shifted from primarily being surgical to a nonoperative approach, which can be attributed to a multitude of reasons, including better understanding of the pathophysiology of SBO, the advent of laparoscopy, and improvement in diagnostic imaging. But given the nature of SBO, the need for surgical consultation continues to remain a necessity. This article will review the etiology, diagnosis, and management of SBO.

Upper Gastrointestinal Bleeding: A Potential Precursor to Bouveret's Syndrome

Bouveret's syndrome is a rare complication of cholelithiasis. It is characterized by a gallstone entering the intestine through a cholecystoenteric fistula, impacting the duodenum and causing gastric outlet obstruction. Rarely, it presents with hematemesis and melena. The diagnosis involves computed tomography (CT) and the treatment depends on the patient's stability, the location of the obstruction, stone size, and the fistula. Endoscopy or minimally invasive lithotripsy can be considered initially. If this fails, surgical intervention is recommended. We present a case of upper gastrointestinal bleeding (UGIB) preceding the development of Bouveret's syndrome.

Gallstone Ileus Treated by Incidental Meckel's Diverticulectomy

Gallstone ileus is an uncommon cause of intestinal obstruction in the elderly. It is typically recognized on computed tomography by the presence of pneumobilia and a gallstone in the right iliac fossa. Nonetheless, it is important to consider that gallstone ileus may represent the presentation of another pathology rather than an entity on its own. Here, we report successful retrieval of a gallstone that was causing ileus. Intraoperatively, the gallstone was noted lodged in the terminal ileum distal to an incidentally noted Meckel’s diverticulum. The gallstone was milked proximally into the Meckel’s diverticulum and the base was transected. This case illustrates a rare, but unique, surgical technique utilizing a small bowel diverticulum as a vector for stone removal.

Role of magnetic resonance imaging in Bouveret's syndrome: A case report with review of the literature

Bouveret's syndrome is a rare form of gallstone ileus occurring due to obstructing gallstone into the proximal duodenum through a cholecystoduodenal fistula. We report the case of a 72-year-old female presenting with abdominal pain secondary to a large gallstone in the region of the duodenal bulb, causing the upstream gastric obstruction. Here we discuss the clinical features, imaging technologies, and surgical management of Bouveret's syndrome.

Gallstone ileus after recent cholecystectomy. Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Gallstone ileus in cholecystectomized patients is very infrequent and when it happens shortly after surgery is even rarer. We report the case of a patient who presented Gallstone ileus few days after open cholecystectomy which has not been reported before in literature.

CASE PRESENTATION

A 52-year-old male with a history of recent open cholecystectomy was referred to our center due to a presumable surgical complication. During his hospitalization while trying to restart the oral route he presented abdominal pain and nausea. He evolved toward a bowel obstruction. We suspected gallstone ileus based on medical history as well as preoperative image study. We confirmed the diagnostic using a Computed Tomography. Surgical management was performed and a large gallstone was extracted from the bowel. The patient progressed favorably and was discharged. He was asymptomatic during the follow-up.

CLINICAL DISCUSSION

Cholecystectomized patients who have been reported with Gallstone ileus demonstrate different pathophysiological mechanisms or extraordinary presentations. This case describes a unique presentation illustrating relevant aspects of this pathology such as showing that acute cholecystitis can be its clinical manifestation or that it could happen after a cholecystoenteric fistula is found during a cholecystectomy.

CONCLUSION

Gallstone ileus in cholecystectomized patients is very rare. Clinical suspicion remains the cornerstone of diagnosis.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Gallstone ileus in a patient with amyotrophic lateral sclerosis: A case report

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Gallstone ileus is an uncommon complication of untreated cholelithiasis affecting an aged population.

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Amyotrophic lateral sclerosis has documented dysautonomia causing significant delays in colonic transit times and gastric emptying.

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Intestinal hypoperistalsis and adrenergic hyperfunctioning may be related to impaired gallbladder contractility resulting in sludge and stone accumulation.

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We present a unique case of gallstone ileus in a patient with amyotrophic lateral sclerosis.

Introduction and importance

Gallstone ileus is a rare disease that most commonly occurs in elderly females with a history of cholelithiasis. It has not been previously associated with Amyotrophic Lateral Sclerosis (ALS); a neurodegenerative disease that primarily affects the motor neurons at the spinal and bulbar levels. Autonomic malfunction, in particular, gastrointestinal dysfunction has been documented in ALS patients which may predispose this population to the development of gallstones and gut dysmotility.

Case presentation

In this paper, we report a case of gallstone ileus in a patient with diagnosed ALS. We performed an exploratory laparotomy, enterolithotomy, and an open cholecystectomy with takedown/closure of a cholecystoduodenal fistula. The patient had a relatively uncomplicated postoperative course and was discharged from the hospital on postoperative day nine.

Clinical discussion

Delays in gastric emptying and colonic transit times in ALS patients may pose a risk for the development of gallstones and the potential impaction of a gallstone ileus in patients who are left untreated. Multifactorial evaluation of this patient population is necessary when assessing a potential causal pattern of gallstone ileus in patients with significant comorbidities.

Conclusion

We present an unusual pathology without an established incidence, which has pertinent multidisciplinary implications. The suspicion of ALS as a potential cause for the development of a gallstone ileus is relevant and essential in the diagnostic workup for an elderly patient who develops a small bowel obstruction with multi-comorbidities.

A Unique Presentation of Bouveret's Syndrome: Two Large Gallstones Obstructing Both the Gastric Outlet and the Common Bile Duct Simultaneously

Bouveret's syndrome refers to a gastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximal duodenum. Thus, it can be considered a very proximal form of gallstone ileus and is infrequent. We describe such a unique case that a female patient presents with Bouveret's syndrome and concomitant common bile duct obstruction by a second gallstone. The decision over its surgical management is complicated, based on risk factors, clinical presentations, radiographic evidence, surgical risk assessment, and specific considerations tailored to individual case. Because of her stable clinical picture and low surgical risk, we proceeded with stone extractions, fistula take-down, and common bile duct exploration in a one-stage procedure. Her postoperative course was complicated by bile stained drainage through closed suction drain that resolved with conservative management.

Gallstone Ileus: Uncommon Presentation Followed by Less Common Spontaneous Resolution

Gallstone ileus is a rare but significant cause of bowel obstruction. An 82-year-old female was admitted to the hospital with abdominal pain and was initially treated for a possible urinary tract infection. Following a surgical review and based on history, clinical examination as well as radiological findings, a diagnosis of gallstone ileus was made. The patient was prepared for surgery; however, whilst awaiting theatre, she spontaneously passed the obstructing gallstone with full resolution of bowel obstruction symptoms. The usual treatment for gallstone ileus is surgical management with an enterolithotomy; nevertheless, this case highlights the importance of close monitoring and adapting a management plan to fit an evolving clinical scenario.

Gallstone Ileus Decades after Cholecystectomy and Pylorus-Preserving Whipples

We report a case of small bowel obstruction due to gallstone ileus found in a patient with previous pancreaticoduodenectomy (Whipple procedure). Investigation by computed tomography of the abdomen showed a transition point in the midjejunum due to a radioopaque intraluminal mass. Following resuscitation, the patient underwent laparotomy to remove the offending mass from the midjejunum. Subsequent stone analysis confirmed a cholesterol-rich gallstone. This is thus the first description of gallstone ileus following Whipple procedure. The rarity of this presentation and a literature review is presented.

Complicating factors in the management of advanced Bouveret syndrome in frail and medically complex patients: Case report and discussion of pathophysiology

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Bouveret’s syndrome results from biliary stones from cholecysto-duodenal fistula.

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Gastric outlet obstruction from duodenal stones has high morbidity and mortality.

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Duodenal gallstones may grow over time, increasing risks of management.

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Delay in diagnosis and stone extraction may result in needing higher risk surgery.

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Tertiary referral of at-risk elderly or frail patients may improve outcomes.

Introduction

Bouveret Syndrome is a rare but important variant of gallstone ileus with high potential for morbidity and mortality. Bouveret syndrome is a complication of gallstone disease resulting from chronic inflammation and subsequent fistulization between the gallbladder and duodenum or stomach with subsequent impaction of the stone in the proximal GI tract. Here we present a case in an elderly man with moderate medical comorbidities.

Presentation of case

An elderly man presented to the hospital with symptoms of gastrointestinal obstruction. Upon further diagnostic work-up, he was noted to have a 5.8 cm gallstone impacted in his proximal GI tract and thus diagnosed with a rare variant of gallstone ileus—Bouveret syndrome.

Discussion

The therapeutic goal in approaching Bouveret syndrome is removal of the stone and improvement in obstruction and cholangitis. This may be accomplished with surgery or endoscopic therapy—although this may be less effective. Bouveret syndrome may have high morbidity.

Conclusion

Bouveret syndrome is a rare but potentially serious syndrome that should be managed accordingly. It should remain on the differential diagnosis of an elderly patient presenting with gastrointestinal obstructions, particularly if there is a history of gallstone disease and concern for proximal GI obstruction.

Focus on management of gallstone ileus

Gallstone ileus is a rare form of intestinal obstruction and an uncommon complication of gallstone disease resulting from the impaction of one or more gallstones in the bowel owing to biliary intestinal fistula. The increasing incidence of gallstone ileus is related to the high prevalence of cholelithiasis, the aging of the population, and the more sensitive diagnostic tools. The diagnosis is often delayed due to the lack of typical clinical manifestations. In this paper, we discuss the pathogenesis of gallstone ileus, factors that result in its diagnosis, and therapeutic strategies by performing a systematic review of the literature. We also emphasize the specificity and complexity of gallstone ileus. We suggest that on the basis of observing the basic principles, the management should be rationalized and individualized in clinical practice so as to improve the prognosis of gallstone ileus.

Technical Approach to Laparoscopic Examination of the Small Bowel in Gallstone Ileus

Background

Gallstone ileus is an infrequent cause of small bowel obstructions (SBO), accounting for only 0.1-5% of SBOs and 25% of nonstrangulating causes of SBO in the elderly population. There is scant literature available regarding the use of laparoscopy to treat gallstone ileus. Currently, much of the literature available is limited to case reports only.

Methods

A complete laparoscopic approach was utilized to manage a 65-year-old woman with morbid obesity who presented with gallstone ileus. With regard to our technical approach, we describe the technical approach that facilitates safe laparoscopic examination of the entire small bowel and can be applied to other acute care surgery cases involving small bowel pathology.

Results

The patient's postoperative course was complicated by new-onset atrial fibrillation which was treated medically with good response. She was safely discharged on postoperative day 2.

Conclusion

Laparoscopy is a feasible option for the management of gallstone ileus and can lead to decreased morbidity compared to laparotomy. The technique described allows for laparoscopic examination of the entire small bowel.

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.

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.

Laparoscopic Approach for Gallstone Ileus in Geriatric Patients

We report two patients who presented with small bowel obstruction secondary to gallstones in the ileum. Both patients were geriatric women with multiple comorbidities. The first patient was a 73-year-old woman who presented with a gallstone eroding and obstructing the duodenum (Bouveret's syndrome) secondary to gallbladder cancer with diffuse metastatic spread to the liver. The stone was disimpacted endoscopically using lithotripsy. The patient presented two days later after the stone had migrated downstream into the small bowel causing obstruction requiring surgical intervention. Second patient was an 81-year-old woman who presented with small bowel obstruction caused by a gallbladder stone impacted in the distal ileum. Both patients were managed laparoscopically with a mini laparotomy to extract the affected segment of bowel loop via small incision on the anterior abdominal wall at the port site with enterolithotomy. Both patients were discharged by postoperative day four with no complications. We conclude that, in elderly patients with multiple comorbidities presenting with gallstone ileus, laparoscopic approach provides early recovery with minimal pain.

Rare recurrent gallstone ileus: A case report

BACKGROUND

The management of recurrent gallstone ileus (GSI) is unsatisfactory, and there is no consensus on how to reduce the incidence of recurrent GSI.

CASE SUMMARY

A 79-year-old man presented to the Emergency Department of our hospital complaining of abdominal pain. An abdominal computed tomography (CT) scan revealed cholecystolithiasis, intrahepatic bile duct dilatation, gas accumulation, small intestinal obstruction, and circular high-density shadow in the intestinal cavity. Emergency surgery revealed that the small intestine had extensive adhesions, unclear gallbladder exposure, obvious adhesions, and difficult separation. The obstruction was located 70 cm between the ileum and the ileocecum, which was incarcerated by gallstones, and a simple enterolithotomy was carried out. On the third day after the operation, he had passed gas and defecated and had begun a liquid diet. On the fifth day after the operation, he suddenly experienced abdominal distension and discomfort. Emergency CT examination revealed recurrent GSI, and the diameter of the stone was approximately 2.0 cm (consistent with the shape of cholecystolithiasis on the abdominal CT scan before the first operation). The patient’s symptoms were not significantly relieved after conservative treatment. On the ninth day after the operation, emergency enterolithotomy was performed again along the original surgical incision. On the twentieth day after the second operation, the patient fully recovered and was discharged from the hospital.

CONCLUSION

We believe that a thorough examination of the bowel and gallbladder for gallstones based on preoperative imaging during surgery and removal of them as far as possible on the premise of ensuring the safety of patients are an effective strategy to reduce the recurrence of GSI.

Bouveret's syndrome as a rare complication of cholelithiasis: Disputes in current management and report of two cases

INTRODUCTION

Bouveret's syndrome is a rare complication of cholelithiasis that determines an unusual type of gallstone ileus, secondary to an acquired fistula between the gallbladder and either the duodenum or stomach with impaction of a large gallbladder stone. Preoperative diagnosis is difficult because of its rarity and the absence of typical symptoms. Adequate treatment consists of endoscopic or surgical removal of obstructive stone.

PRESENTATION OF CASES

Two old females patients were admitted to the Emergency Department with a history of abdominal pain associated with bilious vomiting. Physical examination revealed abdominal distension with tympanic percussion of the upper quadrants, abdominal pain on deep palpation of all quadrants and in the first patient positive Murphy's sign. Preoperative diagnosis of gallstone impacted in the duodenum was obtained by abdominal computed tomography (CT) scan in the first patient and by esophagogastroduodenoscopy in the second one. Both patients underwent surgery with extraction of the gallstone from the stomach. Postoperative course of two patients was uneventful and they were discharged home.

DISCUSSION

Bouveret's syndrome usually presents with signs and symptoms of gastric outlet obstruction. Preoperative radiological investigations not always are useful for its diagnosis. Appropriate treatment, endoscopic or surgical, is debated and must be tailored to each patient considering medical condition, age and comorbidities.

CONCLUSION

Bouveret's syndrome is a very rare complication of cholelithiasis, difficult to diagnose and suspect, because of lack of pathognomonic symptoms. Nowaday there are no guidelines for the correct management of this pathology. Endoscopic or surgical removal of obstructive stone represents the correct treatment.

Cecal Perforation by a Large Gallstone: An Unusual Diagnosis

Cholecystocolic fistulas are uncommon, with rare cases of colonic obstruction described in the literature and even rarer cases of intestinal perforation due to gallstones.

We describe a case of a 73-year-old man who presented to our ED with complaints of diffuse abdominal pain, vomiting, constipation, and fever for the past week. Abdomen CT showed signs of acute perforated appendicitis. An exploratory laparotomy was proposed which revealed cecal perforation caused by a 3 cm gallstone. A right colectomy was performed with primary anastomosis, without cholecystectomy or fistula repair. The postoperative period was complicated due to an anastomotic dehiscence on day 12 with the need for a re-laparotomy with an ileotransverse colostomy confection. The patient was in the ICU care for five days and was discharged on the 13th day after the second intervention. 

The clinical presentation of gallstone ileus is nonspecific and vague often leading to a delay in the diagnosis and treatment. CT scan has the best specificity and sensibility for the diagnosis but abdominal X-ray may show the pathognomonic Rigler´s triad. The surgical treatment consists of removing the gallstone with or without simultaneous cholecystectomy and fistula repair.

Reports of colonic perforation due to gallstones are very scarce, which makes this a very low suspicion diagnosis. The ideal surgical approach is not established. The morbidity of these cases can reach 50%.

Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus

Gallstone ileus is a dramatic complication of gallstone disease, uncommon but not exceptional in a busy emergency department. It represents a cause of mechanical intestinal obstruction, which predominantly occurs in elderly and frail patients; this contributes to the high morbidity and mortality rates associated with this condition. The modern radiologist is frequently asked to determine the cause of bowel obstruction and should be aware of the most pictorial features of this unusual disease. Broadly speaking, abdominal radiography and ultrasonography alone are limited in detecting the cause of bowel obstruction, but the sensitivity for the preoperative diagnosis of gallstone ileus may be improved by combining the findings obtained by both techniques. Computed tomography is the modality of choice for the diagnosis of this disease: it may accurately describe the number, size, and location of migrated gallstones and the exact site of bowel obstruction, providing a detailed preoperative planning. Magnetic resonance imaging may be used in selected cases for an exquisite anatomic definition of the fistulous communication.

Enterocutaneous Fistula: A Simplified Clinical Approach

A “fistula” is an abnormal connection between two epithelial surfaces. Fistulae are named based on the two surfaces or lumens they connect to. Fistulae form due to loss of wall integrity from an underlying insult, leading to the penetrance of an adjacent organ or epithelized surface. Common causes of small bowel fistulae include sequelae of surgical intervention, foreign body, bowel diverticula, Crohn's disease, malignancy, radiation, and infection. A histopathological analysis displays acute and/or chronic inflammation due to the underlying pathology.

A thorough history and physical examination are important components of patient evaluation. Generally, patients will present with non-specific constitutional symptoms in addition to local symptoms attributed to the fistula. In rare instances, symptoms may be severe and life-threatening. Initial laboratory workup includes complete blood count, comprehensive metabolic panel, and lactate level. Radiologic imaging is useful for definitive diagnosis and helps delineate anatomy. In practice, computed tomography (CT) is the initial imaging modality. The addition of intravenous or enteric contrast may be helpful in certain situations. Magnetic resonance imaging (MRI) may also be used in special circumstances. Invasive procedures, such as endoscopy, can assist in the evaluation of mucosal surfaces to diagnose pathology such as inflammatory processes.

Appropriate management should include optimizing nutritional status, delineating fistulous tract anatomy, skincare, and managing the underlying disease. A non-operative approach is generally accepted as the initial approach especially in the acute/subacute setting. However, operative intervention is indicated in the setting of failed non-operative management. Successful management of small bowel fistulae requires a multidisciplinary team approach.

To conclude, a small bowel fistula is a complex clinical disease, with surgical intervention being the most common cause in developed countries. The non-operative approach should be trialed before an operative approach is considered.

Adhesive small bowel obstruction - an update

Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.

Gallstone ileus: a review

Background Gallstone ileus is an important complication of cholecystolithiasis. In general, surgery is the treatment of choice for such cases, but clinicians face difficulty in the selection of an appropriate approach. Closure of a cholecystoenteric fistula can be achieved through one-stage or two-stage operation. Two-stage operation has a lower mortality rate than a one-stage procedure, but persistence of the cholecystoenteric fistula is associated with the risk of carcinogenesis and recurrence of gallstone ileus.

Objective This study reviews the different surgical approaches according to the impaction site of the gallstone, using data of previous studies by our group and clinical reports in the literature.

Conclusions First, for cases involving impaction at the duodenum, the cholecystoenteric fistula can be repaired in the same surgical field, and one-stage operation obtains favourable outcome; hence, one-stage operation is considered as treatment of choice. Second, for cases involving impaction at the small intestine, natural closure of the cholecystoenteric fistula or low mortality is expected; hence, two-stage operation may be performed, possibly using minimally invasive laparoscopy. Third, for cases involving impaction at the colon, natural closure of the cholecystocolonic fistula is unlikely, and patients have a high risk of reflux cholangitis due to faecal fluid; hence, one-stage operation is considered as treatment of choice.

Gallstone ileus managed with enterolithotomy

Although gallstone disease is classically associated with the inflammatory sequela of cholecystitis, other presentations include gallstone ileus, Mirizzi syndrome, Bouveret syndrome and gallstone ileus. Gallstone ileus occurs when a gallstone passes from a cholecystoduodenal fistula into the gastrointestinal tract and causes obstruction, usually at the ileocaecal valve. It represents an uncommon complication of cholelithiasis, accounting for 1%-4% of all cases of mechanical bowel obstruction and 25% of all cases in individuals aged >65 years. It has a female predilection. Clinical presentation depends on the site of the obstruction. Diagnosis can prove challenging with the diagnosis rendered in 50% of cases intraoperatively. The authors present the case of a 79-year-old woman with a 10-day history of abdominal pain, nausea, vomiting and episodes of loose stools. An abdominal radiograph showed mildly distended right small bowel loops. Further investigation with a CT of the abdomen and pelvis demonstrated small bowel obstruction secondary to a 3.3 cm calculus within the small bowel. She underwent a laparotomy and a 5.0×2.5 cm gallstone was evident, causing complete obstruction. An enterolithotomy was performed. Her postoperative course was complicated by Mobitz type II heart block requiring pacemaker insertion. This paper will provide an overview of the clinical presentation, investigations and management of gallstone ileus. It provides a cautionary reminder of considering gallstone ileus in the differential diagnosis in elderly patients presenting with bowel obstruction and a history of gallstone disease.

An emergency case of small bowel obstruction due to multiple gallstones in a limited resource setting

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Gallstone ileus is a rare condition accounting for 5% of all intestinal obstruction cases in which the mortality rate is relatively high (25%).

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Preoperative diagnosis is a major challenge because the symptoms are unspecific and diagnosis is often established intraoperatively.

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Surgical treatment with enterolithotomy alone is recommended for geriatric patients with concomitant comorbidities.

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Enterolithotomy alone might also be suitable in the case of emergency because of less clinical complications and comparable outcomes.

Introduction

Gallstone ileus is an uncommon intestinal obstruction caused by impaction of gallstones passing through the cholecysto-intestinal fistula. Diagnosis of gallstone ileus remains a major challenge because the symptoms and signs are unspecific and the recommended laboratory examinations are not always available particularly in limited health resource settings including in Indonesia. In addition, treatment of choice is still debatable involving enterolithotomy only with or without additional cholecystectomy and fistula repair in one or two-stage surgery.

Presented case

A 49 years old overweight Javanese woman presented in the emergency room with nausea, frequent vomiting, abdominal distension, and absence of defecation in the past 3 days before admission. Previous abdominal surgery and history of biliary disease were not reported during anamnesis. Plain abdominal X-rays revealed small bowel obstruction. Upon emergency laparotomy, the mechanical bowel obstruction was caused by multiple gallstones in the terminal ileum.

Discussion

Although the incidence of gallstone ileus is 5% of all intestinal obstruction cases, the mortality rate is around 25%. Diagnosis is often difficult and half of the cases are diagnosed intraoperatively. Surgical management is still controversial involving enterolithotomy with or without cholecystectomy and fistula repair in one or two stage procedure.

Conclusions

Although the incidence is rare, elaborating thorough anamnesis, physical and basic laboratory examinations in gastrointestinal obstruction should consider gallstone ileus as a potential differential diagnosis particularly in a patient with any risk factors of the biliary disease. Enterolithotomy only might be acceptable for any emergency case due to the equivalent clinical outcomes and relatively low complications.

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.