Recurrent gallstone ileus: beware of the faceted stone

Gallstone ileus in a middle-aged male with an atypical history: a case report

Currently, gallstone ileus is an unusual complication of cholelithiasis (0.3–3.0 %) and a rare cause of mechanical bowel obstruction (0.1–4.0 %). The rarity of the condition makes it impossible to plan the large prospective randomized clinical trials, so the analysis of case reports is significant for decision making in the management of gallstone ileus. We report a case of gallstone ileus in a middle-aged male who had a history of surgery for duodenal ulcer perforation in past. A combination of peptic ulcer disease and cholelithiasis is based on a reduced gastrointestinal hormones secretion. Clinical specialists need to consider information about the greater frequency and asymptomatic clinical course of gallstone disease against a background of duodenal ulcer. Duodenal ulcer scar and bulbar deformity may promote to the cholecystoduodenal fistula formation. In the presence of an acute bowel obstruction symptoms and the absence of gallbladder instrumental examination results, it is possible to recommend the prior gastroduodenoscopy for the pre-operative pneumobilia detection. The optimal surgical approaches for acute gallstone ileus are still controversial.

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.

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.

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

We present a pictorial review of a range of typical and atypical cases of gallstone ileus (GI), across a wide range of imaging modalities. GI is a complication of gallstone disease causing mechanical intestinal obstruction due to impaction of gallstone in the gastrointestinal tract. The spectrum of presentation can vary enormously, and we highlight the importance of accurate imaging diagnosis of GI especially early use of computed tomography. This will lead to timely and appropriate surgical intervention with the potential avoidance of unnecessary outcomes. The ambition of pictorial synopsis is to make the radiologists to be more vigilant to the common and more obscure imaging findings of GI.

Laparoscopic Management of a Proximal Jejunal Gallstone Ileus with Patulous Ampulla and Choledochal Cyst-a Report of Unusual Presentation and a Review

Gallstone ileus is a diagnosis of rarity, and a proximal site of obstruction in a young patient is even rare. Of the three cases in our experience, we found two cases of gallstone ileus (GSI) with typical epidemiology and presentation, one had combination of multiple rare associations. We report such a case, suspected to have gallstone ileus on ultrasound and confirmed diagnosis on computed tomography. Presence of biliary-enteric fistula, old age, and obstructive features, as in typical cases, was a bigger asset for diagnosis, but it was difficult to entertain diagnosis of GSI in young girl in absence of a demonstrable biliary-enteric fistula, with uncommon association of choledochal cyst and sickle cell disease. A very surprising finding, dilated major papilla, could however explain the pathogenesis which has also been reported in the past. Although differential opinions regarding management exist, we decided to follow two-stage surgery as our institute protocol. A minimal access approach has been immensely helpful in accurate diagnosis, and expedative management with early recovery has been proven in the past studies which we agreed with our experience.

A chip off the old block—A case report of gallstone ileus in which identification of a facetted stone was essential in preventing re-laparotomy

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Interesting case discussing a comparatively rare but serious presentation.

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Important operative learning point to avoid return to theatre and associated morbidity/mortality.

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Excellent intra-operative images to highlight learning points.

Gallstone ileus is a rare presentation, accounting for 0.1% of cases of mechanical small bowel obstruction. Patients are often elderly with significant comorbidity. Treatment is based upon laparotomy and enterolithotomy. We present the case of a 75 year old lady admitted as an emergency with a 4 day history of small bowel obstruction. She was found on CT scan to have an impacted gallstone in the distal ileum. At operation, her impacted stone was removed through a proximal enterostomy. The stone however was found to have a squared off edge, raising the suspicion of a second fragment within the proximal small bowel lumen. Failure to retrieve this could have led to re-obstruction requiring a return to theatre and repeat laparotomy in an elderly patient with the associated morbidity.

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.