Cholecystectomy and fistula closureversus enterolithotomy alone in gallstone ileus

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: 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.

A curious case of cololithiasis

Gallstone ileus is an uncommon cause of bowel obstruction that involves cholecystoenteric fistulation and resultant passage of gallstones into the bowel. In the vast majority of cases, the fistula forms between the gallbladder and duodenum leading to small bowel obstruction. We report a case of cholecystocolic fistulation and subsequent large-bowel obstruction in a 75-year-old woman who presented acutely after taking a bowel preparation for an outpatient colonoscopy during the course of an investigation of anaemia and nonspecific abdominal pain. Preintervention imaging revealed a giant gallstone at the rectosigmoid junction, in the presence of a cholecystocolic fistula, and subsequent large bowel obstruction. After a failed period of expectant management, laparotomy and Hartmann's procedure were performed and the patient made an uneventful recovery.

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

INTRODUCTION

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

PRESENTATION OF CASE

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

DISCUSSION

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

CONCLUSION

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

Gallstone ileus: monocentric experience looking for the adequate approach

Common complications of biliary lithiasis are cholecystitis, bile duct lithiasis, and acute biliary pancreatitis. Gallstone ileus is uncommon complications often requiring surgical approach. It is a mechanical bowel obstruction caused by a biliary calculus usually originating from a bilioenteric fistula. Because of the limited number of reported cases, the optimal surgical method of treatment has been the subject of ongoing debate. A retrospective, observational, descriptive study was conduct on patients diagnosed with non-neoplastic bowel occlusion. For each case of gallstone ileus, the following variables were revised: personal and clinical data, mean time of onset of symptoms, length of pre- and postoperative stay, imaging studies, biochemical tests, site of the bilioenteric fistula and occlusion, surgical strategy, postoperative course, follow-up, and mortality. Of the 290 cases of non-neoplastic bowel obstruction from 2008 to 2015, 11 (3.7%) were due to gallstone ileus. The majority of patients were elderly women (F 9/M 2) with high average age (82.4; 76-88) and significant comorbidities. Five cases of small-bowel occlusions were treated with solely enterolithotomy. For the remaining six cases, digestive resection and cholecystectomy were performed. Complications rate (20 vs. 80%) and postoperative stay (12.4 vs. 25.3 days) were lower in the group of enterolithotomy with respect to the group treated with other procedures. In-hospital mortality was nil. Gallstone ileus is an uncommon bowel occlusion affecting mainly the elderly female population. Enterotomy with stone extraction alone is associated with better outcomes than more invasive techniques.

Gallstone ileus from a non-calcified stone: a challenging diagnosis

Gallstone ileus is an uncommon and often life-threatening complication of cholelithiasis. In this case, we discuss a difficult diagnostic case of gallstone ileus with a non-calcified gallstone. An 88-year-old female presented with abdominal pain and vomiting. A CT scan was arranged and showed an evolving bowel obstruction although no frank hyperdensity suggestive of a gallstone was noted. Initially the cause of the bowel obstruction was uncertain, but after discussion with the treating team and further review of the images, the patient was diagnosed with gallstone ileus. The patient underwent emergency surgery and a 41 mm obstructing calculus was removed from the patient's jejunum, later confirmed on histological diagnosis.

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.

Gallstone ileus - the double challenge: case report and review of the literature

Gallstone ileus is a rare condition which occurs as an evolutive complication of biliary lithiasis. It occurs after stone migration from extrahepatic biliary tree to the digestive lumen, mostly through a biliary-enteric fistula. This condition involves repeated inflammatory relapses with the formation of local adhesions and generally requires a long evolution. The vast majority of patients with biliary ileus are third aged women who often have concomitant medical illnesses. Gallstone ileus surgery deals with the two components: bowel obstruction and biliary pole. Obstruction solving is approached as a surgical emergency and it requires an attitude adapted to the local situation. The attitude towards biliary surgery for gallstone ileus is a matter in debate. It could be one-stage surgery, elective surgery or expectancy and its choice is imposed by both local and general condition of the patient. We report the case of a middle-age woman whose first symptom of cholelithiasis was the gallstone ileus. Plain upright abdominal radiography revealed air-fluid levels with distended loops of the small bowel and pneumobilia. Laparotomy was decided and exploration revealed an impacted gallstone into the ileum and dense adhesions were found under the liver region. Enterolithotomy for gallstone removal was made. Postoperative evolution was uneventful with discharge on 7th day.

Gallstone ileus, clinical presentation, diagnostic and treatment approach

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract. Less than 1% of cases of intestinal obstruction are derived from this etiology. The symptoms and signs of gallstone ileus are mostly nonspecific. This entity has been observed with a higher frequency among the elderly, the majority of which have concomitant medical illness. Cardiovascular, pulmonary, and metabolic diseases should be considered as they may affect the prognosis. Surgical relief of gastrointestinal obstruction remains the mainstay of operative treatment. The current surgical procedures are: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and fistula closure (one-stage procedure); and (3) enterolithotomy with cholecystectomy performed later (two-stage procedure). Bowel resection is necessary in certain cases after enterolithotomy is performed. Large prospective laparoscopic and endoscopic trials are expected.

Response of gallstone ileus to conservative therapy

We report a case of cholelithiasis followed by gallstone ileus, documented with serial computed tomography (CT) scans, that responded to conservative therapy. An 80-year-old woman was admitted because of abdominal pain and vomiting. Six months previously, she had presented with abdominal pain and nausea of sudden onset. A CT scan showed thickening of the gallbladder wall and a gallbladder stone. She refused cholecystectomy, and the abdominal pain gradually improved in response to conservative treatment. On admission, plain abdominal radiographs showed obstruction of the proximal small bowel. A CT scan revealed disappearance of the gallbladder stone, fluid-filled bowel loops, and the presence in the small bowel of an impacted stone (major axis, 45 mm; minor axis, 23 mm). We diagnosed gallstone ileus. Because the gallstone was not large, we inserted a stomach tube and administered conservative treatment. One day after admission, CT showed that the impacted stone had migrated to the transverse colon. Four days after admission the impacted stone was not seen on plain abdominal radiography. Five days after admission, follow-up CT revealed pneumobilia but no impacted stone. Because the symptoms had improved the patient resumed oral intake of liquids The patient was discharged 14 days after admission and is doing well.

Management and outcome of recurrent gallstone ileus: A systematic review

AIM

To help the surgeon in decision making when treating a patient with recurrent gallstone ileus (RGSI).

METHODS

A systematic review related to RGSI was performed using the databases CINAHL, EMBASE, MEDLINE via PubMed from May 1912 to April 2015. All languages were included and the grey literature was also searched. The abstracts were explored for relevance to the topic and full texts obtained as appropriate. A manual search was carried out by scrutinising the reference lists of all the full text articles and further articles were identified and obtained. Total of 903 articles were identified, 656 were excluded after abstract review, 247 full text articles were reviewed and 91 articles selected for final analysis. There were 113 cases of RGSI.

RESULTS

There were 113 cases of RGSI reported in 91 articles. The majority of the recurrences, 62.6%, occurred within 6 wk of the index event. The male to female ratio was 1:7. The mean age was 69.6 years (SD 11.2) with a range of 38-95 years. The small bowel was the commonest site of impaction (92.2%). Treatment data was available for 104 patients. The two main operations performed were: (1) Enterolithotomy without repair of biliary fistula in 70.1% of all patients with a procedural mortality rate of 16.4% (12/73) and (2) a single stage surgery approach involving enterolithotomy with cholecystectomy and repair of the biliary enteric fistula in 16.3% with a procedural mortality of 11.7% (2/17). A subset analysis over last 25 years showed mortality from eneterolithotomy was 4.8% while single stage mortality was 22.2%. Enterolithotomy alone was the commonest operation performed for RGSI with four patients (5.4%) having a further recurrence of gallstone ileus.

CONCLUSION

Enterolithotomy alone or followed by a delayed two-stage treatment approach is the preferred choice offering low mortality and reduced risk of recurrence.

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.

Recurrent gallstone ileus due to a residual gallstone: A case report and literature review

•

Recurrence should be considered in all patients with gallstone ileus.

•

A review of pre-operative imaging and meticulous inspection of the bowel and gallbladder should always be undertaken.

•

Faceted gallstones should alert the surgeon to the potential presence of a second stone.

•

Cholecystolithotomy should be considered as a safer alternative to cholecystectomy with fistula repair in high risk patients.

Introduction

Mechanical small bowel obstruction is an uncommon but important complication of cholelithiasis. Recurrent gallstone ileus has historically been considered a rare occurrence; however, the incidence is likely to be underreported and the condition carries a high mortality rate.

Presentation of case

We present a case in which a 67 year old man suffered a recurrence of gallstone ileus 10 days after his initial enterolithotomy, requiring further laparotomy.

Discussion

We review the literature to highlight potential clinical predictors as well as the benefits and pitfalls of management options in preventing repeated episodes of gallstone ileus in the same patient.

Conclusion

The presence of multifaceted gallstones and multiple stones of size ≥ 2cm on pre-operative imaging should alert the clinician to potential for recurrence.

Laparoscopic management of Bouveret syndrome

Bouveret syndrome is a proximal form of gallstone ileus where a large gallstone lodges in the pylorus or proximal duodenum, having passed through a bilioenteric fistula that has formed secondary to previous cholecystitis. We describe the laparoscopic extraction of a giant 'Bouveret' gallstone from the duodenum of an elderly man with morbid obesity.

Gallstone Ileus following Endoscopic Stone Extraction

An 85-year-old woman was an outpatient treated at Tokyo Rosai Hospital for cirrhosis caused by hepatitis B. She had previously been diagnosed as having common bile duct stones, for which she underwent endoscopic retrograde cholangiopancreatography (ERCP). However, as stone removal was unsuccessful, a plastic stent was placed after endoscopic sphincterotomy. In October 2012, the stent was replaced endoscopically because she developed cholangitis due to stent occlusion. Seven days later, we performed ERCP to treat recurring cholangitis. During the procedure, the stone was successfully removed by a balloon catheter when cleaning the common bile duct. The next day, the patient developed abdominal pain, abdominal distension, and nausea and was diagnosed as having gallstone ileus based on abdominal computed tomography (CT) and abdominal ultrasonography findings of an incarcerated stone in the terminal ileum. Although colonoscopy was performed after inserting an ileus tube, no stone was visible. Subsequent CT imaging verified the disappearance of the incarcerated stone from the ileum, suggesting that the stone had been evacuated naturally via the transanal route. Although it is extremely rare for gallstone ileus to develop as a complication of ERCP, physicians should be aware of gallstone ileus and follow patients carefully, especially after removing huge stones.

Single-incision laparoscopic surgery for gallstone ileus: An alternative surgical procedure

INTRODUCTION

Gallstone ileus (GI) results from the passage of a stone through a cholecystoenteric fistula, subsequently causing a bowel obstruction. The ideal treatment procedure for GI remains controversial.

PRESENTATION OF CASE

A 63-year-old female was admitted to our hospital following persistent nausea and vomiting for 7 days. Computed tomography revealed a partially calcified 4-cm circular object in the jejunum, and the proximal intestine was dilated, with concomitant pneumobilia. Based on the preoperative diagnosis of GI, enterotomy with stone extraction by single-incision laparoscopic surgery (SILS) was performed. The patient's postoperative course was uneventful, and the cholecystoduodenal fistula closed spontaneously 4 months after the surgery.

DISCUSSION

Recent studies have reported that enterotomy with stone extraction alone is associated with better outcomes than with more invasive techniques. This case also suggests that enterotomy with stone extraction alone and careful postoperative follow-up is feasible for the management of GI. Although the use of laparoscopy in the management of GI has been described previously, laparoscopic surgery has not been widely performed, and SILS is not generally performed. When only this less demanding procedure is required, laparoscopic surgery, including SILS, can be a viable option.

CONCLUSION

SILS can be an alternative surgical procedure for the management of GI.

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

Background

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

Description

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

Conclusions

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

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

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

Bouveret's syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy

BACKGROUND

Bouveret's syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. It is a rare condition that causes significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnostic and treatment strategies are required for optimal management and outcome. The purpose of this paper is to develop a surgical strategy for optimized individual treatment of Bouveret's syndrome based on the available literature and motivated by our own experience.

CASE PRESENTATION

Two cases of Bouveret's syndrome are presented with individual management and restrictive surgical approaches tailored to the condition of the patients and intraoperative findings.

CONCLUSIONS

Improved diagnostics and restrictive individual surgical approaches have shown to lower the mortality rates of Bouveret's syndrome. For optimized outcome of the individual patient: The medical and perioperative management and time of surgery are tailored to the condition of the patient. CT-scan is most often required to secure the diagnosis. The surgical approach includes enterolithotomy alone or in combination with simultaneous or subsequent cholecystectomy and fistula repair. Lower overall morbidity and mortality are in favor of restrictive surgical approaches. The surgical strategy is adapted to the intraoperative findings and to the risk for secondary complications vs. the age and comorbidities of the patient.

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.

Twice recurrent gallstone ileus: a case report

Introduction

Gallstone ileus is a rare cause of bowel obstruction and results from the passage of gallstones into the bowel.

Case presentation

We present the case of an 83-year-old Caucasian woman who had three episodes of gallstone ileus, each of which was managed with simple enterotomy. This sequence is one of the first reported in the medical literature and may be seen to challenge the traditional surgical approach of enterotomy alone.

Conclusions

The available evidence comparing enterotomy alone with combined enterotomy, cholecystectomy, and fistula closure in the management of gallstone ileus is reviewed. Neither approach is clearly identified as superior, but available series suggest that simple enterotomy may be safer than a combined approach and does not result in a higher rate of recurrent biliary disease.

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

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

Bouveret's syndrome: a case report and a review of the literature

Bouveret's syndrome is a gastric outlet obstruction caused by an impacted gallstone that passes through a cholecysto-gastric or cholecysto-duodenal fistula. An elderly woman visited a local clinic with nausea and abdominal pain. Abdominal computed tomography revealed a stone that was impacted in the duodenal lumen and a fistula between the gallbladder and duodenum. Malignancy could not be excluded due to the mass in the cystic duct showing enhancement and the presence of enlarged lymph nodes on computed tomography, and increased fludeoxyglucose uptake in the cystic duct on positron emission tomography. The patient underwent simultaneous cholecystectomy, segmental duodenectomy and gastro-jejunostomy. Pathological examination exhibited chronic inflammation and no primary cancer of the gallbladder and fistula.

Gallstone ileus: correlation between computed tomography, double-balloon enteroscopy and intra-operative findings

Gallstone ileus is an uncommon cause of small bowel obstruction, affecting mainly elderly patients. We report a case of gallstone ileus in an 88-year old female patient. The correlation between computed tomography, double-balloon enteroscopy and intra-operative findings is discussed, as well as treatment strategies.

Once bitten, twice incised: recurrent gallstone ileus

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

Bouveret's syndrome with a concomitant incidental T1 gallbladder cancer

Bouveret's syndrome, which is a gastric outlet obstruction caused by a gallstone in the duodenum, is a rare complication of gallstone disease. We report a case of Bouveret's syndrome in an 81-year-old woman who also exhibited incidental gallbladder cancer. She was admitted to our hospital complaining of upper abdominal pain and vomiting. A computed tomography examination showed a cholecystoduodenal fistula, a large impacted stone at the gastric outlet, and a dilated stomach. She was diagnosed as having Bouveret's syndrome. The patient underwent an upper gastrointestinal endoscopy and a mechanical lithotripsy was successfully performed for the stone. She then underwent a cholecystectomy with primary closure of the duodenal fistula. An intra-operative histopathology examination revealed severe cholecystitis with an adenocarcinoma in part of the gallbladder. Gallbladder bed resection and regional lymph node dissection were also performed. To the best of our knowledge, this is the first published report of a case in which Bouveret's syndrome and gallbladder cancer co-existed.

The operative management of gallstone ileus

INTRODUCTION

Gallstone ileus is an uncommon entity, which accounts for 1-4% of all presentations to hospital with small bowel obstruction and for up to 25% of all cases in patients over 65 years of age. Despite medical advances over the last 350 years, gallstone ileus is still associated with high rates of morbidity and mortality. The management of gallstone ileus remains controversial. Whilst open surgery has been the mainstay of treatment, more recently other approaches have been employed, including laparoscopic surgery and lithotripsy. However, controversy persists primarily in relation to the extent of surgery performed.

MATERIALS AND METHODS

A literature review was performed in an attempt to discover the optimal surgical treatment of gallstone ileus, particularly the timing of biliary surgery. Published articles were identified from the medical literature by electronic searches of Pubmed and Ovid Medline databases, using the search terms 'gallstone ileus', 'gallstone/intestinal obstruction' and 'gallstone/bowel obstruction'. The related articles function of the search engines was also used to maximise the number of articles identified. Relevant articles were retrieved and additional articles were identified from the references cited in these articles.

RESULTS AND CONCLUSIONS

The literature on gallstone ileus is composed entirely of retrospective analysis of small numbers of patients accumulated over many years. The question as to whether one stage or interval biliary surgery should be performed remains unanswered and it is unlikely that further case series will help decision making in the management of gallstone ileus. Whilst many authors conclude that enterolithotomy alone is the best option in most patients, a one-stage procedure should be considered for low-risk patients.

Recurrent recurrent gallstone ileus

We describe the second reported case of three consecutive episodes of gallstone ileus and ask the question whether recurrent gallstone ileus justifies definitive surgery to the fistula itself or can be safely managed by repeated enterotomies.

Gallstone ileus: One-stage surgery in a patient with intermittent obstruction

Gallstone ileus, an uncommon complication of cholelithiasis, is described as a mechanical intestinal obstruction due to impaction of one or more large gallstones within the gastrointestinal tract. The clinical presentation is variable, depending on the site of obstruction, manifested as acute, intermittent or chronic episodes. A 51-year-old female patient was referred to our hospital with 3 events of intestinal obstruction during the previous 7 d. At admission, there were clinical signs of intestinal obstruction; abdominal film demonstrated dilated bowel loops, air-fluid levels and a vague image of a stone in the inferior left quadrant. Once stabilized, a laparotomy was performed. Surgical findings were distention of the jejunum and ileum proximal to a palpable stone in the ileum as well as gallstones and a cholecystoduodenal fistula in the gallbladder. An enterolithotomy, repair of the cholecystoduodenal fistula and cholecystectomy were performed. The postoperative course was uneventful. There is no uniform surgical procedure for this disease. When the patient is too ill or when biliary surgery is not advisable, an enterolithotomy is the best option. The one-stage procedure should be the offered to adequately stabilized patients when local and general conditions, such as good cardiorespiratory and metabolic reserve permit a more prolonged surgical procedure.

Ileo biliar - uma complicação da doença calculosa da vesícula biliar

O íleo biliar representa de 1 a 4% dos casos de obstrução intestinal mecânica e decorre da impactação de cálculos biliares na luz intestinal. Relatamos o caso de uma paciente portadora de cálculo da vesícula assintomática, que apresentou este tipo de complicação e necessitou tratamento cirúrgico de urgência, discutindo a etiopatogenia, aspectos diagnósticos e terapêuticos dessa afecção. O diagnóstico baseou-se na anamnese, exame físico e exames complementares, particularmente nos exames de imagem. Foi realizada laparotomia exploradora com enterotomia e retirada do cálculo e enterorrafia, sem manipulação da vesícula ou da fístula bilio-entérica. Evoluiu no pós-operatório com complicações respiratórias, necessitando ventilação mecânica e acabou falecendo no vigésimo pós-operatório. Concluímos que a doença calculosa vesicular pode provocar o aparecimento de complicações graves e de tratamento cirúrgico de urgência, razão pela qual devemos pensar na indicação da colecistectomia eletiva, particularmente em doentes sintomáticos e com risco cirúrgico baixo, independentemente da idade.

A rare variant of gallstone ileus: Bouveret's syndrome

INTRODUCTION

Bouveret's syndrome (gastric outlet obstruction due to impaction of a stone) is a rare variant of gallstone ileus. A recently observed case led us to review the literature, with the aim to discuss the recent advances in the management of this rare syndrome.

DISCUSSION

A 69-year-old woman was admitted with symptoms of high intestinal obstruction. Computed tomography scan of the abdomen showed a large gallstone impacted in the duodenum. One-stage surgery, consisting in enterolithotomy, cholecystectomy, and fistula repair, was carried out. Although several surgical and nonoperative procedures have been used, the optimal treatment of Bouveret's syndrome remains controversial. Surgery still maintains a prominent position, even though nonoperative procedures have an increasing role especially in high risk patients with important comorbidities. The decision should be taken on an individual basis, after evaluating patient's general condition and age, stone size, comorbidities influencing the operative risk, and expertise of surgical and endoscopic teams. One-stage surgery may offer definitive management in selected patients.

Roux-en-Y duodenojejunostomy in the treatment of Bouveret syndrome

Bouveret syndrome is a rare complication of cholelithiasis occurring when a gallstone passes through a cholecystoduodenal or choledochoduodenal fistula and lodges in the pylorus or proximal duodenum causing a gastric outlet obstruction. The case of a 70-year-old male who developed Bouveret syndrome is presented, and the management of this presentation of gallstone ileus by Roux-en-Y duodenojejunostomy is discussed in detail.

Bouveret's syndrome: case report and review of the literature

Bouveret's syndrome is defined as gastric outlet obstruction caused by duodenal impaction of a large gallstone which passes into the duodenal bulb through a cholecystogastric or cholecystoduodenal fistula. Initial attempts at endoscopic retrieval with or without mechanical or extracorporeal lithotripsy should be performed as first-line treatment, though success rates with endoscopic treatment are variable. We describe a case of Bouveret's Syndrome in an elderly patient that was successfully treated with endoscopic extraction combined with mechanical lithotripsy, and review the literature on this uncommon condition.

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

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

Gallstone ileus: surgical strategies and clinical outcome

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Endoscopically assisted minimally invasive surgery for gallstones

BACKGROUND

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

METHODS

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