Pictorial review: the pearls and pitfalls of the radiological manifestations of gallstone ileus

Laparoscopic surgery for gallstone ileus

We present a case of a woman in her 70s who arrived in the emergency department with signs of small-bowel obstruction. CT scanning revealed acute cholecystitis with a cholecystoduodenal fistula, pneumobilia and small-bowel obstruction possibly secondary to gallstone ileus although no radio-opaque gallstones were seen. The patient underwent an emergency operation and intra-operative findings revealed mechanical small-bowel obstruction of the proximal jejunum where a 4×2 x 3 cm gallstone was impacted. A laparoscopic-assisted enterotomy was performed with stone extraction and primary closure. The patient made a full recovery. A planned laparoscopic cholecystectomy and repair of cholecystoduodenal fistula is scheduled on elective basis.

Incidentally Found Cholecystoduodenal Fistula and an Unusual Case of Gallstone Ileus After Laparoscopic Cholecystectomy

Gallstone ileus, a rare and potentially fatal complication of cholelithiasis, occurs when gallstones breach the gastrointestinal tract through a fistula, causing an obstruction and potentially leading to severe complications. This case report details the experience of a 44-year-old woman with gallstone ileus stemming from an unnoticed cholecystoduodenal fistula following a routine cholecystectomy. The fistula was only discovered during surgery despite advanced imaging, revealing extensive adhesions. The discovery led to a subtotal cholecystectomy and fistula repair. Postoperatively, complications arose, prompting a computed tomography scan to rule out further issues. However, she later returned with gallstone ileus, necessitating a second operation. This case underscores the importance of thorough intraoperative exploration for biliary enteric fistulas during cholecystectomy, potentially averting the need for subsequent interventions. The case also highlights the diagnostic challenges of gallstone ileus and the significance of clinical suspicion.

Gallstone Ileus—Lessons from a Missed Diagnosis

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

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.

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.

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.

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.

Evaluation and diagnosis of gallstone ileus using point of care ultrasound in the Emergency Department

A 75-year-old female presented to the Emergency Department (ED) with nausea, feculent emesis and abdominal distension. On previous visit the patient was diagnosed with a 2.2x1.9x1.1 cm ectopic gallstone in the mid small bowel without evidence of ileus or bowel obstruction and was subsequently discharged home. She returned 2 days later, abdominal plain radiographs revealed mildly dilated small bowel with air-fluid levels and a calcified mass in the right hemipelvis. Bedside ultrasound was performed and an air filled gallbladder with a fistulous tract was visualized. Dilated loops of bowel were visualized with an abnormal back and forth movement of intestinal contents, consistent with a small bowel obstruction. Patient went on to have an uncomplicated surgical extraction of the gallstone with resolution of her ileus. We would propose using point-of-care ultrasonography with abdominal plain films as an adjunct for evaluation and diagnosis of gallstone ileus in elderly patients.

Clinical and radiological diagnosis of gallstone ileus: a mini review

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

A case of Bouveret's syndrome treated with gastrojejunal anastomosis

Bouveret's syndrome is a rare cause of proximal gallstone ileus with obstruction of duodenum or gastric outlet. We report a case of an 87-year-old female patient presented with 1 week history of vomiting whose plain radiograms showed ileus and pneumobilia. The abdominal computed tomography confirmed pneumobilia and revealed free air and leakage of oral contrast agent in the hepatic hilum and subhepatic space and an impacted gallstone in the third portion of the duodenum. The patient underwent exploratory laparotomy, which showed that the duodenal perforation was circumvallated, and a side-to-side retrocolic gastrojejunal anastomosis was performed in order to surpass the impacted gallstone. Removal of the impacted gallstone through enterotomy or gastrotomy or endoscopic lithotripsy is the usual treatment of Bouveret's syndrome. However, gastrojejunal bypass may be a treatment option when the patient undergoes laparotomy and the gallstone is impacted in the third or fourth portion of the duodenum.