Gallstone ileus

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.

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.

Emergency ultrasound and gallstone ileus

Gallstone ileus is an uncommon cause of mechanical obstruction due to a biliary stone that wedges the intestinal lumen. It is a surgical emergency representing a clinical and diagnostic challenge: the clinical manifestations are rarely specific, often causing diagnostic delay that can adversely affect the prognosis. Emergency ultrasound could be useful in assessing the level and identifying the cause of bowel obstruction. We report a case of a 74-year-old patient with a 6-day history of constipation and crampy abdominal pain without previous history of abdominal diseases. Emergency ultrasound led to an early diagnosis showing dilated small bowel loops with a shadowing mass inside consistent with an ileal stone, in the absence of aberrant located stone on plain abdominal film.

[Gallstone Ileus: results of analysis of a series of 40 patients]

Gallstone ileus is an infrequent surgical emergency that nevertheless represents a not insignificant percentage of occlusions of the small intestine without strangulation. We present a retrospective study of 21 years (1980-2000) in 40 patients. Mean age was 76 years and most of the patients (85%) were women. Mean age and associated disease increased throughout the study period. Cases of gallstone ileus decreased in the second and third 5-year periods and clearly increased in the fourth (1996-2000). Localization of gallstones was ileum in 25 patients, jejunum in 9, duodenum in 3, colon in 1 and feces in 2. Only 12 patients (30%) received a correct preoperative diagnosis. Treatment was surgical in 38 patients with 7.5% mortality and 57.5% morbidity. Enterolithotomy was the technique of choice. A high degree of suspicion for gallstone ileus and early treatment may be the factors required to improve prognosis. The increase in life expectancy and associated comorbidity, which contraindicate elective surgery for cholelithiasis, may be contributing towards an increase in the population prone to developing gallstone ileus.