Ir J Med Sci (2010) 179:151–153 DOI 10.1007/s11845-008-0194-3
CASE REPORT
Gallstone ileus: a difficult emergency diagnosis! B. Memon Æ H. Sharma Æ M. A. Anwar Æ M. A. Memon
Received: 14 October 2007 / Accepted: 10 July 2008 / Published online: 17 September 2009 Ó Royal Academy of Medicine in Ireland 2008
Abstract Gallstone ileus (GSI) is a rare cause of mechanical small bowel obstruction. It occurs when a fistula between the gallbladder and the small bowel facilitates the migration of gallstone(s) into the small bowel. The commonest site of impaction is in the terminal ileum. We report the case of a 71-year-old female presenting with GSI diagnosed on CT scan. She was surgically explored and gallstones extracted by a simple enterotomy leading to full recovery of the patient.
of one or more gallstones which enter the small bowel usually via a cholecystoenteric fistula. It is reported to have a high mortality rate ranging between 0 and 50% because it generally affects females of advanced age with concomitant medical disorders [1, 2, 4]. We report the case of a 71year-old female presenting with GSI and managed successfully with simple enterolithotomy.
Case report Keywords Gallstones Small bowel obstruction Enterolithotomy
Introduction Gallstone ileus is an uncommon clinical entity [1–3] and accounts for 1–4% of cases of mechanical obstruction of the small bowel [3]. It is caused by intraluminal impaction
B. Memon M. A. Memon (&) Department of Surgery, Ipswich Hospital, Chelsmford Avenue, Ipswich, QLD 4305, Australia e-mail:
[email protected] H. Sharma M. A. Anwar Department of Surgery, Whiston Hospital, Prescot, Merseyside, UK M. A. Memon Department of Surgery, University of Queensland, Herston, QLD, Australia M. A. Memon Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
A 71-year-old Caucasian female presented with a history of generalised colicky abdominal pain associated with persistent nausea and vomiting. Physical examination showed a soft non-distended abdomen with slight tenderness in the epigastrium and right lower quadrant. The only relevant past medical history was colonic Crohn’s disease diagnosed 20 years ago via colonoscopy. However, she had been completely asymptomatic from Crohn’s point of view and was not on any medications. At the time of admission, her routine blood investigations revealed a high white cell count with neutrophilia, high urea and creatinine and abnormal liver function tests. An ultrasound scan of the abdomen failed to reveal any gallstones or dilated biliary ducts. Her plain films of abdomen and chest at the time of admission were within normal limits. She was managed conservatively initially with analgesia and antiemetics. However, she continued to complain of grumbling abdominal pain, nausea and vomiting. Repeated blood investigations 3 days later revealed complete normalisation of her blood chemistry including LFTs. However, her repeated abdominal film revealed gas in the biliary tree raising the suspicion of a cholecystoenteric fistula. As the patient continued to have abdominal pain and vomiting, an upper gastrointestinal endoscopy was performed. This revealed oesophagitis,
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gastric erosions and duodenitis along with ulcers in both the oesophagus and duodenum but no obstructive lesion. Biopsies, however, failed to reveal anything sinister and she was negative for H. pylori. The patient was treated with Esomeprazole, a proton pump inhibitor, on the basis of her gastroscopic findings. A flexible sigmoidoscopy only revealed diverticular disease but no signs of Crohn’s disease and random colonic biopsies turned out to be normal. The patient nonetheless failed to settle and continue to complain of abdominal pain associated with vomiting. She therefore underwent an urgent double contrast CT scan of the abdomen which revealed two concentric calcified opacities within the small bowel causing small bowel dilatation (Figs. 1, 2). Furthermore the radiologist reported the
presence of gas within the biliary tree but was not able to identify the gallbladder (Fig. 3). Based on these findings, an urgent laparotomy was performed and two gallstones were removed via a small enterotomy in the mid ileum (Figs. 4, 5). The enterotomy site was marcospically normal and there were no strictures noted in the small bowel from the duodenojejunal flexure to ileocaecal junction (ruling out small bowel Crohn’s disease). Examination of the gallbladder area revealed a large omental phlegmon completely obscuring the gallbladder and the duodenum and therefore any definitive surgery for gallbladder was abandoned. The patient made a steady recovery following her surgery and was discharged home on the 7th postoperative day.
Fig 1 CT of the abdomen showing a gallstone (white arrow, GS) in the jejunum causing dilated small bowel loops (DSBLs) proximally Fig 3 CT of the abdomen showing air in the biliary tree (white arrow)
Fig 2 CT of the abdomen showing a gallstone (white arrow, GS) at the ileocaecal junction
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Fig 4 Intraoperative photograph showing two gallstones in the small bowel lumen (white arrow)
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biliary tract [3]. Definitive biliary surgery especially during the emergency setting leads to prolonged operating time, is technically demanding and carries the risk of enteric and biliary leakage leading to even higher mortality, up to 50% [1]. We opted for a simple enterotomy due to our patient’s advanced age and the operative findings of a large phlegmon completely obscuring the gallbladder and duodenal anatomy. This certainly led to a swift and simple operative procedure on our patient with complete recovery.
Conclusions
Fig 5 Small enterotomy (white arrow) with the two extracted black gallstones
Discussion Gallstone ileus occurs due to the passage of gallstone(s) into the small bowel via a cholecystoduodenal fistula and is characterised by intermittent intestinal obstruction [3]. This is probably due to the migration and distal impaction of gallstones with peristalsis and is called tumbling phenomenon [3]. It is mostly detected on radiological investigations such as plain abdominal X-ray, but a CT scan of the abdomen is considered as the investigation of choice in detecting not only gallstones but concomitant abnormalities such as gallbladder pathology etc. Rigler’s triad of ectopic gallstone, pnemobilia and bowel obstruction strongly support the diagnosis of GSI on CT of the abdomen [2, 3]. This triad was evident in our patient (Figs. 1, 2, 3). Controversy persists regarding the emergency surgical treatment of GSI [2, 3, 5]. Options available include simple enterotomy and removal of gallstones ± cholecystectomy and repair of cholecystoduodenal fistula either during primary presentation or as a staged procedure [2, 3, 6]. Enterolithotomy is the simplest option although leaving the diseased gallbladder and cholecystoenteric fistula can predispose the patient to recurrent GSI, recurrent cholecystitis and recurrent cholangitis. However, complications related to unresected cholecystoenteric fistula are rare and only 10% of patients eventually require reoperation for conditions related to the
Gallstone ileus remains an uncommon cause of mechanical small bowel obstruction and its diagnosis in an emergency situation can be a daunting task. This condition is associated with a high mortality rate because it occurs in elderly frail patients with multiple co-morbidities and delayed diagnosis. The treatment remains debatable. However, the majority of surgeons favour the simple and quick approach of enterolithotomy in these high-risk patients in whom prolonged operation is best avoided.
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