A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy

Gallstone Ileus as an Occult Cause of Small Bowel Obstruction and Subsequent Large Bowel Obstruction: A Report of a Rare Case

Gallstone ileus, a rare cause of mechanical bowel obstruction, occurs due to the formation of a cholecystenteric fistula allowing gallstones to migrate into the gastrointestinal tract. The condition occurs mostly in elderly patients, particularly women, and carries a significant mortality risk due to delayed diagnosis. This case report discusses a 77-year-old female patient with a history of chronic medical conditions, who self-presented with periumbilical pain, nausea, and reduced bowel movements. Initial imaging revealed pneumobilia and small bowel obstruction, leading to a diagnosis of partial obstruction attributed to adhesions. Despite surgical intervention and temporary symptom relief, the patient's condition deteriorated due to a subsequent colonic obstruction. The case was complicated by delayed recognition of gallstone ileus, as imaging initially misinterpreted the obstructive mass as a "stool ball" rather than a gallstone. Following diagnostic laparoscopy and subsequent exploratory surgeries, the patient was found to have a gallstone impacted in the rectum, leading to colonic ischemia and perforation. This resulted in progressive renal failure, respiratory failure, and ultimately, the patient's death in hospice care. This case underscores the diagnostic challenges of gallstone ileus and highlights two key delays: misattribution of obstructive symptoms to adhesions and failure to recognize colonic obstruction due to gallstone ileus. Early use of contrast-enhanced imaging and a high index of suspicion are crucial for timely diagnosis. This case emphasizes the importance of thorough inspection of the small bowel and ileocecal region during laparoscopy and the need for careful evaluation of imaging findings to improve patient outcomes in gallstone ileus cases.

Controversial Surgical Approach to Recurrent Gallstone Ileus

Gallstone ileus is a rare but potentially serious complication of gallstone disease, which presents as a mechanical intestinal obstruction due to impaction and fistulization of a gallstone, most commonly in the small intestine. Since it usually occurs in elderly patients, the symptoms can be very diverse and with a late presentation. We present the case of a 90-year-old patient with intestinal obstruction and acute abdominal pain who experienced gallstone ileus and underwent surgery, and a few days after being discharged returned with a recurrence of the symptoms, was re-operated, and a second stone was found.

Navigating Challenges: Managing Upper Gastrointestinal Bleeding From Cholecystoduodenal Fistula in an Elderly Patient

Cholecystoduodenal fistula (CDF) is an uncommon condition characterized by an abnormal connection between the gallbladder and the duodenum, often linked to cholelithiasis. It typically presents with nonspecific symptoms such as abdominal pain and jaundice but can occasionally result in severe upper gastrointestinal (GI) bleeding. This report describes the case of a 94-year-old female who presented with hypovolemic shock and multiple episodes of hematemesis. An upper GI endoscopy confirmed a CDF with active hemorrhage. Due to her comorbidities and poor performance status, an endoscopic approach using hemostatic spray was chosen, resulting in a favorable clinical outcome. The development of CDF is typically a result of chronic gallbladder inflammation and cholecystitis, leading to adhesion and erosion into the duodenum. Diagnosis involves imaging and endoscopic techniques, and management varies based on the patient's condition, encompassing surgical, endoscopic, or conservative approaches. This case highlights the necessity of considering CDF in the differential diagnosis of upper GI bleeding, especially in patients with recurrent cholecystitis, and emphasizes the importance of individualized management strategies. It is notable for the use of a minimally invasive endoscopic technique to manage a high-risk patient, highlighting an alternative to surgical intervention.

Letter to the editor RE: "Gallstone ileus - A rare presentation in the era of rampant cholecystectomies"

•There are three main surgical options for treatment of gallstone ileus. •Enterolithotomy alone is frequently mentioned in the literature as the best option in most patients. •Individual patient characteristics are crucial when selecting the least morbid surgical option.

Gallstone ileus- A rare presentation in the era of rampant cholecystectomies

INTRODUCTION

Gallstone ileus is a rare but potentially dangerous complication of cholelithiasis and represents about 1 % of the total cases of small bowel obstruction (Balthazar and Schechter, 1978).

PRESENTATION OF CASE

We report a case of 40 years old female who presented with signs and symptoms of bowel obstruction. On further investigation, a diagnosis of gallstone ileus was established. She was managed by laparoscopy-assisted enterolithotomy.

DISCUSSION

Gallstone ileus, a form of mechanical intestinal obstruction, predominantly affects elderly females. Surgical management options includes enterolithotomy alone, two-staged enterolithotomy with delayed cholecystectomy and fistula repair, and single staged enterolithotomy and fistula repair. A laparoscopy-assisted enterolithotomy allows simultaneous direct diagnosis of gallstone ileus and assessment of pericholecystic adhesions along with cholecystoenteral fistula.

CONCLUSION

Laparoscopy-assisted enterolithotomy was chosen for managing gallstone ileus in this patient, omitting cholecystectomy and fistula repair due to dense adhesions. The patient remained symptom free for 6 months post-surgery, suggesting potential spontaneous closure of the cholecystoduodenal fistula, affirming the viability of this less invasive approach.

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.

Surgical Treatment of Gallstone Ileus: Less Is More

INTRODUCTION

The objective of this study was to evaluate the need for cholecystectomy in patients who underwent surgery for gallstone ileus.

METHODS

This was a retrospective review of the clinical history of patients who underwent surgery for gallstone ileus between December 1992 and December 2018 and follow-up until October 2020. Data regarding the surgical intervention, location of the obstruction, and surgical procedure performed were collected, as well as complications in relation to biliary pathology in the postoperative period.

RESULTS

Twenty-five patients underwent surgery for gallstone ileus. In all patients, except one, the site of the obstruction was identified. The mean age of the patients was 72 (standard deviation [SD] 13.3) years, with a female predominance (18: 7). The patients presented symptoms, on average, 2.9 (1-7) days before going to the emergency room; the primary symptoms were vomiting associated with abdominal pain and constipation (56%). Fifty-six percent of patients were diagnosed preoperatively by imaging tests. In 72% of patients, an enterolithotomy was performed alone without any other intervention on the gallbladder or bile duct. Eighty-three percent of the patients did not present any cholecystobiliary complications during the entire follow-up period, and urgent or delayed cholecystectomy was not performed after the acute episode.

CONCLUSIONS

Gallstone ileus is a rare entity, and there are no randomized studies that support a preferred treatment. If surgical intervention is required, enterotomy for stone extraction is a safe and effective technique, and in our experience, urgent or delayed cholecystectomy is not necessary.

Cholecystoduodenal fistula resulting in gallstone ileus: A path paved by stone

This report showcases the initial management of gallstone ileus which includes proper biliary assessment to assist with operative planning. While an uncommon condition, surgical management is crucial, although methodology may be variable.

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.

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.

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.