Gallstone ileus treated with non-surgical conservative methods: a case report

Distal jejunal gallstone ileus-an unusual cause of bowel obstruction: a case report

Gallstone ileus is a rare entity that causes bowel obstruction by gaining access through a cysto-enteric fistula. This is a case report of a 70-year-old man presenting with small bowel obstruction secondary to distal jejunal gallstone ileus impaction. He is not known to have any predisposing factors. He was managed effectively with an enterolithotomy. Early diagnosis is key to a good prognosis. Although other management options are available, enterolithotomy with or without cholecystectomy remains the gold standard of management.

Bouveret Syndrome: A Rare Case and Review of the Literature

Bouveret syndrome is a subtype of gallstone ileus, wherein a calculus becomes entrapped in the duodenum via a cholecystocolic fistula, leading to gastric outlet obstruction. Due to the non-specific symptoms the patients present with, a diagnosis is reliant on computed tomography (CT), magnetic resonance imaging (MRI) or direct endoscopic visualisation. We report a case of Bouveret syndrome and review current literature, outlining the aetiopathogenesis and management strategies of this condition.

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.

Focus on management of gallstone ileus

Gallstone ileus is a rare form of intestinal obstruction and an uncommon complication of gallstone disease resulting from the impaction of one or more gallstones in the bowel owing to biliary intestinal fistula. The increasing incidence of gallstone ileus is related to the high prevalence of cholelithiasis, the aging of the population, and the more sensitive diagnostic tools. The diagnosis is often delayed due to the lack of typical clinical manifestations. In this paper, we discuss the pathogenesis of gallstone ileus, factors that result in its diagnosis, and therapeutic strategies by performing a systematic review of the literature. We also emphasize the specificity and complexity of gallstone ileus. We suggest that on the basis of observing the basic principles, the management should be rationalized and individualized in clinical practice so as to improve the prognosis of gallstone ileus.

Gallstone Ileus: An Unusual Cause of Intestinal Obstruction

Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal obstruction. Typically as a result of the formation of cholecystoduodenal fistula, surgical removal of the gallstone is the mainstay of treatment in order to relieve the intestinal obstruction. A 34-year-old male with no history of cholelithiasis presented with features of a small bowel obstruction. CT scan of the abdomen demonstrated pneumobilia, a cholecystoduodenal fistula and small bowel obstruction, features suspicious for a gallstone ileus. The patient underwent a laparotomy and removal of two gallstones via an enterotomy. He was discharged home after an uneventful post-operative period. Gallstone ileus is an uncommon cause of mechanical bowel obstruction with often delayed presentation and non-specific symptoms. A high level of suspicion is required in at-risk groups, and in patients presenting with a bowel obstruction and known gallstone disease.

Gallstone ileus: monocentric experience looking for the adequate approach

Common complications of biliary lithiasis are cholecystitis, bile duct lithiasis, and acute biliary pancreatitis. Gallstone ileus is uncommon complications often requiring surgical approach. It is a mechanical bowel obstruction caused by a biliary calculus usually originating from a bilioenteric fistula. Because of the limited number of reported cases, the optimal surgical method of treatment has been the subject of ongoing debate. A retrospective, observational, descriptive study was conduct on patients diagnosed with non-neoplastic bowel occlusion. For each case of gallstone ileus, the following variables were revised: personal and clinical data, mean time of onset of symptoms, length of pre- and postoperative stay, imaging studies, biochemical tests, site of the bilioenteric fistula and occlusion, surgical strategy, postoperative course, follow-up, and mortality. Of the 290 cases of non-neoplastic bowel obstruction from 2008 to 2015, 11 (3.7%) were due to gallstone ileus. The majority of patients were elderly women (F 9/M 2) with high average age (82.4; 76-88) and significant comorbidities. Five cases of small-bowel occlusions were treated with solely enterolithotomy. For the remaining six cases, digestive resection and cholecystectomy were performed. Complications rate (20 vs. 80%) and postoperative stay (12.4 vs. 25.3 days) were lower in the group of enterolithotomy with respect to the group treated with other procedures. In-hospital mortality was nil. Gallstone ileus is an uncommon bowel occlusion affecting mainly the elderly female population. Enterotomy with stone extraction alone is associated with better outcomes than more invasive techniques.

Gallstone Ileus Caused by Cholecystocolonic Fistula and Gallstone Impaction in the Sigmoid Colon: Review of the Literature and Novel Surgical Treatment with Trephine Loop Colostomy

Gallstone ileus is an uncommon cause of intestinal obstruction and occurs following the formation of a cholecystoenteric fistula, permitting passage of gallstones into the gastrointestinal tract. Impaction of a gallstone in the sigmoid colon is rare and is usually at sites of previous colonic disease. Definitive management can be challenging due to the advanced age and co-morbidity usually seen in this group of patients. We describe a patient successfully managed with on-table endoscopy and, under local anaesthetic, the formation of a left iliac fossa trephine loop colostomy, permitting an enterolithotomy to deliver the stone whilst accommodating for severe pre-existing distal sigmoid diverticular disease. A review of the literature identified various endoscopic and surgical treatments that, depending on local expertise and patient characteristics, can be considered on a case-by-case basis. We advocate the management described in this case for patients presenting with large bowel obstruction due to gallstone ileus, with a background of diverticular disease and who are not fit for general anaesthetic or formal bowel resection, as an alternative to medical palliation alone.

Bowel obstruction and perforation due to a large gallstone. A case report

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Gallstone obstruction is a rare clinical entity presenting usually in elderly patients and is associated with a medical history of biliary symptoms.

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CT examination uncovered all findings consisting Rigler’s triad, thus air in the gall bladder, bowel obstruction and a gallstone inside the bowel lumen. It also identified a cholecystoduodenal fistula.

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Rupture of the small bowel occurred intraoperatively, and a large 3.2 cm gallstone was located in the terminal ileum, which was recovered.

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Post-surgical recovery was uneventful with no further report of obstruction symptoms at 6 month follow up.

Introduction

Gallstone bowel obstruction is a rare form of mechanical ileus usually presenting in elderly patients, and is associated with chronic or acute cholecystitis episodes.

Case presentation

We present the case of an 80 year old female with abdominal pain, inability to defecate and recurrent episodes of diarrhea for the past 8 months. CT examination uncovered a cholecystoduodenal fistula along with gas in the gall bladder and the presence of a ≥2 cm gallstone inside the small bowel lumen causing obstruction. Patient was admitted to the operating room, where a 3.2 cm gallstone was located in the terminal ileus. A rupture was found in the antimesenteric part of a discolored small bowel segment, approximately 60 cm from the ileocaecal valve, through which the gallstone was recovered. The bowel regained its peristalsis, and the rupture was debrided and sutured. Patient was discharged uneventfully on the 6th postoperative day.

Discussion

Gallstone ileus is caused due to the impaction of a gallstone inside the bowel lumen. It usually passes through a fistula connecting the gallstone with the gastrointestinal tract. It can present with nonspecific or acute abdominal symptoms. CT usually confirms the diagnosis, while there are a number of treatment options; conservative, minimal invasive and surgical. Our patient was successfully relieved of the obstruction through recovery of the gallstone using open surgery, with no repair of the fistula.

Conclussion

Although rare, gallstones must be suspected as a possible cause of bowel obstruction, especially in elderly patients reporting biliary symptoms.

How to apply clinical cases and medical literature in the framework of a modified "failure mode and effects analysis" as a clinical reasoning tool--an illustration using the human biliary system

BACKGROUND

Clinicians use various clinical reasoning tools such as Ishikawa diagram to enhance their clinical experience and reasoning skills. Failure mode and effects analysis, which is an engineering methodology in origin, can be modified and applied to provide inputs into an Ishikawa diagram.

METHOD

The human biliary system is used to illustrate a modified failure mode and effects analysis. The anatomical and physiological processes of the biliary system are reviewed. Failure is defined as an abnormality caused by infective, inflammatory, obstructive, malignancy, autoimmune and other pathological processes. The potential failures, their effect(s), main clinical features, and investigation that can help a clinician to diagnose at each anatomical part and physiological process are reviewed and documented in a modified failure mode and effects analysis table. Relevant medical and surgical cases are retrieved from the medical literature and weaved into the table.

RESULTS

A total of 80 clinical cases which are relevant to the modified failure mode and effects analysis for the human biliary system have been reviewed and weaved into a designated table. The table is the backbone and framework for further expansion. Reviewing and updating the table is an iterative and continual process. The relevant clinical features in the modified failure mode and effects analysis are then extracted and included in the relevant Ishikawa diagram.

CONCLUSIONS

This article illustrates an application of engineering methodology in medicine, and it sows the seeds of potential cross-pollination between engineering and medicine. Establishing a modified failure mode and effects analysis can be a teamwork project or self-directed learning process, or a mix of both. Modified failure mode and effects analysis can be deployed to obtain inputs for an Ishikawa diagram which in turn can be used to enhance clinical experiences and clinical reasoning skills for clinicians, medical educators, and students.

Gallstone ileus inducing obstructive jaundice at the afferent loop of Roux-en-Y hepaticojejunostomy after bile duct cancer surgery: a case report

The diagnosis of gallstone ileus is occasionally challenging due to the variability of its presentation. We herein present a very rare case of gallstone ileus inducing obstructive jaundice at the afferent loop of Roux-en-Y hepaticojejunostomy after 10 years of bile duct cancer surgery. We describe the case of a 74-year-old Korean woman with obstructive jaundice, treated conservatively. She showed severely impaired liver function test and obstructive jaundice. The computed tomography (CT) scan led to a diagnosis of very rare type of gallstones ileus at the afferent jejunal loop. Since the clinical manifestation was improved, we decided to observe her closely. On the next follow-up CT scan, the gallstone disappeared with mild distension of the afferent bowel loop, implicating spontaneous passage of the gallstone. She recovered and returned to normal life after 10 days of initiation of clinical manifestations. We presume that the gallstone may enter the afferent jejunal loop through the hepaticojejunostomy and later increase in size. The presence of narrow tract of intestine may facilitate the incidence of gallstone ileus. It appears to be the first report on this rare type of gallstone ileus inducing obstructive jaundice.