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Evolving Gallstone Ileus
SUNY – Downstate
Case Conference
January 12, 2012
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Initial Presentation
• HPI: 90 yo F c 1wk h/o abdominal pain and N/V. Denied F/C. Passing flatus/BM.
• PMH: DM, HTN, CAD.
• PSH: C-sections x 3.
• Meds: Enalapril, HCTZ, Plavix, Colace
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Exam
• VS: 97.2 54 197/76 17 99%RA
• WDWD, NAD
• RRR
• CTAB
• Soft, mildly distended, nontender.
• Well healed Pfannenstiel scar.
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Labs
• CBC 4.9 / 10 / 32 / 290
• BMP 139 / 3.5 / 103 / 24 / 11 / 0.83 / 198
• Amy 37 / Lip 5
• AST 21 / ALT 16 / TB 0.5
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Hospital Course
• Admitted for observation.
• Negative MRCP.
• Symptoms resolved.
• Discharged to home on regular diet.
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Second Presentation
• Returned to ED 3 days post d/c, with recurrence of symptoms.
• Exam unchanged.
• Labs – CBC 6.3 / 12 / 38 / 271
– BMP 137 / 5.4 / 100 / 26 / 14 / 0.78 / 122
– Amy 53 / Lip 15
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Hospital Course
• Readmitted for observation.
• Symptoms resolved; tolerated diet.
• At 1 week, abrupt ab distention, N/V.
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Operative Intervention
• Underwent uneventful enterolithotomy.
• Remaining bowel unremarkable.
• Dense adhesions in the RUQ.
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Hospital Course
• Started diet POD 7.
• Postop course complicated by refractory afib/flutter.
• Discharged to rehab facility POD 22.
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Questions
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Gallstone Ileus
• Mechanical obstruction caused by intraluminal impaction of one or more gallstones anywhere between the stomach and the rectum.
• S/Sx frequently nonspecific.
• Elderly patient with comorbid conditions.
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Epidemiology
• 1-4% of all cases of intestinal obstruction in general population.
• 25% of nonstrangulated SBO over age of 65.
• Mean age 65 to 75.
• Accurate preop diagnosis in 24 to 73% of cases.
Reisner RM, et al. Am Surg. 1994;60(6):441-446.
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Pathogenesis
• 60-80% have demonstrable bilioenteric fistula. – 60% cholecystoduodenal fistulas
• 20-30% have complex RUQ mass on laparotomy.
• Fistulas can occur between the biliary tree and stomach, small bowel, large bowel.
• Bilioenteric fistulas may be associated with surgery, gall bladder carcinoma, duodenal ulcers, and IBD.
van Hillo M, et al. Surgery. 1987;101(3):273-276.
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Related Eponyms
• Mirizzi Syndrome
• Bouveret Syndrome
• Rigler’s Triad
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Related Eponyms
• Mirizzi Syndrome – Common hepatic duct or CBC obstruction caused
by compression from GS in cystic duct or Hartmann’s pouch
• Bouveret Syndrome – Gastric outlet obstruction caused by GS impaction
in distal stomach or duodenum
• Rigler’s Triad – Bowel obstruction, pneumobilia, ectompic
gallstone.
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Anatomy
• Stones may pass spontaneously through Ampulla of Vater.
• 90% of obstructing GS > 2cm in diameter. • Impaction occurs in:
– Ileum 60.5% – Jejunum 16.5% – Stomach 14.2% – Colon 4.1% – Duodenum 3.5%
Clavien PA, et al. Br J Surg. 1990;77(7):737-742.
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Presentation
• Abdominal pain, distention, and vomiting.
• Obstruction 50-70%. Frequently, intermittent. “Tumbling obstruction.”
• Previous hx of gallstone disease did not contribute to diagnosis.
van Hillo M, et al. Surgery. 1987;101(3):273-276.
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Signs and Symptoms www.downstatesurgery.org
Radiographic Findings
• Air/contrast in biliary tree.
• Visualization of stone in the intestine.
• Change in position of previously identified stone.
• Partial or complete obstruction.
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Other Studies
• Plain X-ray – May demonstrate pneumobilia, enterolith.
• US – May be useful in identifying fistula or enterolith
movement during bowel peristalsis.
• Endoscopy – May directly identify fistula.
Lasson A, et al. Eur J Surg. 1995;161(4):259-263. Lassandro F, et al. AJR Am J Roentgenol. 2005;185(5):1159-1165.
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AXR www.downstatesurgery.org
CT www.downstatesurgery.org
AXR www.downstatesurgery.org
CT www.downstatesurgery.org
Endoscopy www.downstatesurgery.org
Treatment
• Surgery – enterolithotomy (open vs laparoscopic).
• Inspection of entire bowel (small and large). – Multiple stones have been reported in 3-40% of
Pts.
• Extracorporeal shockwave lithotripsy successfully employed.
Ravikumar R, et al. Ann R Coll Surg Engl. 2010;92(4):279-281.
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Cholecystenteric Fistula
• 1 Stage – enterolithotomy, cholecystectomy, fistula repair.
• 2 Stage – enterolithotomy.
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1 Stage
• Prevents recurrence. – Up to 17% have recurrent GSI.
– Prevents cholecystitis, cholangitis.
• GB Ca higher in Pts with cholecystenteric fistula.
Clavien PA, et al. Br J Surg. 1990;77(7):737-742. Redaelli CA, et al. Surgery. 1997;121(1):58-63.
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2 Stage
• Most consider enterolithotomy sufficient. – Pt population high risk.
– Recurrence low – less than 5%
– Reoperation rate less than 10%
• Increased morbidity and mortality.
Doko M, et al. World Journal of Surgery. 2003;27(4):400-404. Reisner RM, et al. Am Surg. 1994;60(6):441-446. Tan Y, et al. Singapore Med J. 2004;45(2):69–72.
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Take-Aways
• GSI may be the source of unusual presentations of pneumobilia, SBO, or abdominal pain.
• For the typical GSI Pt, enterolithotomy is sufficient.
• Inspect entire small bowel for multiple GS.
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References 1. Ravikumar R, Williams JG. The operative management of gallstone ileus. Ann R Coll Surg Engl. 2010;92(4):279-281.
2. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6):441-446.
3. Zaliekas J, Munson JL. Complications of gallstones: the Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of “lost” gallstones. Surg. Clin. North Am. 2008;88(6):1345-1368, x.
4. Doko M, Zovak M, Kopljar M, et al. Comparison of Surgical Treatments of Gallstone Ileus: Preliminary Report. World Journal of Surgery. 2003;27(4):400-404.
5. Tan Y, Wong W, Ooi L, others. A comparison of two surgical strategies for the emergency treatment of gallstone ileus. Singapore Med J. 2004;45(2):69–72.
6. Redaelli CA, Büchler MW, Schilling MK, et al. High coincidence of Mirizzi syndrome and gallbladder carcinoma. Surgery. 1997;121(1):58-63.
7. Shiwani MH, Ullah Q. Laparoscopic enterolithotomy is a valid option to treat gallstone ileus. JSLS. 2010;14(2):282-285.
8. van Hillo M, van der Vliet JA, Wiggers T, et al. Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature. Surgery. 1987;101(3):273-276.
9. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg. 1990;77(7):737-742.
10. Brennan GB, Rosenberg RD, Arora S. Bouveret Syndrome1. Radiographics. 2004;24(4):1171 -1175.
11. Lasson A, Lorén I, Nilsson A, Nirhov N, Nilsson P. Ultrasonography in gallstone ileus: a diagnostic challenge. Eur J Surg. 1995;161(4):259-263.
12. Lassandro F, Romano S, Ragozzino A, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol. 2005;185(5):1159-1165.
www.downstatesurgery.org