Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus

Gallstone ileus: report of two cases and a mini literature review

Gallstone ileus is a relatively rare complication of cholelithiasis, and an uncommon cause of small bowel obstruction most commonly seen in elderly and debilitated people with associated comorbidities. Symptoms of gallstone ileus are insidious and may be vague while the delay in diagnosis results in a high mortality rate. Herein we report two cases of gallstone ileus in elderly patients with complex medical history who presented at the emergency department with abdominal pain and distension, vomiting and fluid/electrolyte disorders due to cholecysto-enteric fistula and bowel obstruction.

Radiological Diagnosis and Surgical Treatment of Gallstone Ileus

We report on the diagnosis and treatment of a patient who presented with a small bowel obstruction due to gallstone ileus. This condition is an infrequent complication of cholelithiasis that presents with non-specific and intermittent findings, including bloating, early satiety, constipation, nausea, and vomiting. Contrast-enhanced CT features the classic imaging finding, called Rigler's triad, which includes small bowel distension, gas in the gallbladder, and an ectopic gallstone. Laparoscopic enterolithotomy is employed to prevent further erosion through the gallbladder wall and into the adjacent gastrointestinal structures. The early diagnosis and treatment of gallstone ileus results in decreased morbidity and mortality.

Single stage surgical management of a sigmoid gallstone ileus case

Bowel obstruction/ileus is a relatively common occurrence in surgical practice with a predictable clinical presentation and management course. Rarely are these cases found consistent with gallstone etiology. Known as gallstone ileus (GI), this uncommon presentation is found primarily in elderly females (age > 65 years old) with multiple comorbid conditions; usually with coinciding presence of a cholecystoenteric fistula. Surgical management remains controversial due to the rarity of presentation and complexity of related pathological process. We present a case of a 69-year-old female who presented with typical signs/symptoms of bowel obstruction but found to have sigmoid GI on computed tomography imaging evaluation. A single stage exploratory laparotomy with simple enterolithotomy was performed with a positive outcome and uncomplicated postoperative recovery. The primary goal in reporting this case is to continue emphasizing the efficacy of a single stage simple enterolithotomy as the most ideal surgical management of this rare condition.

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.

A Rare Case of Cholecystoduodenal Fistula Complicated With Gallstone Ileus and Upper Gastrointestinal Bleeding

Gallstone ileus is a rare presentation of cholelithiasis, which usually impacts the narrowest part of the bowel, the ileocecal valve. This occurs as a result of a bilioenteric fistula where a gallstone passed through and entered the gastrointestinal tract. It is most commonly encountered in elder patients and predominantly in females. Abdominal computed tomography is the investigation of choice for diagnosis in the majority of cases. Here, we present a 68-year-old female patient with a choledochoduodenal fistula complicated by upper gastrointestinal bleeding and gallstone ileus.

Back Propagation Neural Network-Based Magnetic Resonance Imaging Image Features in Treating Intestinal Obstruction in Digestive Tract Diseases with Chengqi Decoction

This study was to explore the adoption effect of magnetic resonance imaging (MRI) image features based on back propagation neural network (BPNN) in evaluating the curative effect of Chengqi Decoction (CD) for intestinal obstruction (ileus), so as to evaluate the clinical adoption value of this algorithm. Ninety patients with ileus were recruited, and the patients were treated with CD and underwent MRI scans of the lower abdomen. A BPNN model was fabricated and applied to segment the MRI images of patients and identify the lesion. As a result, when the overlap step was 16 and the block size was 32 × 32, the running time of the BPNN algorithm was the shortest. The segmentation accuracy was the highest if there were two hidden layer (HL) nodes, reaching 97.3%. The recognition rates of small intestinal stromal tumor (SIST), colon cancer, adhesive ileus, and volvulus of MRI images segmented by the algorithm were 91.5%, 88.33%, 90.3%, and 88.9%, respectively, which were greatly superior to those of manual interpretation (P < 0.05). After the intervention of CD, the percentages of patients with ileus that were cured, markedly effective, effective, and ineffective were 65.38%, 23.16%, 5.38%, and 6.08%, respectively. The cure rate after intervention of CD (65.38%) was much higher in contrast to that before intervention (13.25%) (P < 0.05). In short, CD showed a good therapeutic effect on ileus and can effectively improve the prognosis of patients. In addition, MRI images based on BPNN showed a good diagnostic effect on ileus, and it was worth applying to clinical 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.