|Year : 2019 | Volume
| Issue : 3 | Page : 164-166
Gall stone ileus with cholecystoduodenal fistula
Elangkumaran Vellode Manoharan, P Kanakarajan, G Ramkumar, E Selvakumar
Department of Emergency, Apollo Hospitals, Chennai, Tamil Nadu, India
|Date of Submission||19-Jun-2019|
|Date of Acceptance||17-Aug-2019|
|Date of Web Publication||11-Sep-2019|
Elangkumaran Vellode Manoharan
645 and 646, T. H. Road, Apollo Hospitals, Tondiarpet, Chennai - 600 081, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Gallstone ileus and cholecystoduodenal fistula are rare and life-threatening conditions which are due to cholelithiasis and recurrent attacks of cholecystitis. It predominantly affects female population. The signs and symptoms are non-specific, sometimes only established during surgery. Prompt surgical management would avoid the complications and reduce the hospital stay.
Keywords: Cholelithiasis, chronic calculus cholecystitis, duodenal fistula, enterolithotomy, gall stone, Rigler's triad
|How to cite this article:|
Manoharan EV, Kanakarajan P, Ramkumar G, Selvakumar E. Gall stone ileus with cholecystoduodenal fistula. Apollo Med 2019;16:164-6
| Introduction|| |
A gallstone-induced mechanical obstruction of the small bowel is known as “gallstone ileus,” which is a rare complication of cholelithiasis. It accounts for 1%–4% of all cases of intestinal obstruction, but up to 25% of the cases are comprised of patients over 65 years of age, with a female: male ratio of 3.5–6:1. It generally develops secondary to fistulas formed between gallbladder or biliary tract and small intestine, following recurrent attacks of cholecystitis. The morbidity and mortality of gallstone ileus are high, most likely due to misdiagnosis and delayed diagnosis. Computed tomography (CT) imaging is most often used in the investigation of gallstone ileus; only minority of gallstones has sufficient calcium content to be visible on the abdominal X-rays. Here, we report a case of gallstone ileus with cholecystoduodenal fistula causing intestinal obstruction due to large gallstones in the jejunum, with interesting CT findings and successful treatment in one-stage operation.
| Case Report|| |
A 58-year-old female euglycemic, normotensive patient was brought to emergency with a history of bilious vomiting, loose stools 4–5 episodes, high-grade intermittent fever, and progressive abdominal pain for the past 3 days. On physical examination, she was dehydrated, febrile, tachycardia, mild diffuse tenderness of the abdomen, and increased bowel sounds. Hence, she was initially treated with intravenous (IV) fluids, IV anti-emetics, IV proton pump inhibitors, and other supportive management. Initial blood investigations revealed total count of 13,200, elevated erythrocyte sedimentation rate at 41 mm/h, and C-reactive protein at 105.8 mg/L; liver and renal function tests were unremarkable. However, the symptoms persisted despite the conservative management; hence, urgent ultrasound was taken, it showed cholelithiasis and gallstone ileus (dilated small bowel loops with reduced peristalsis and calculus within). A 320 slice CT-abdomen with contrast [Figure 1] and [Figure 2] was done which revealed chronic calculus cholecystitis with fistula [Figure 1] to duodenum resultant passage of gallstones with gallstone ileus. Rigler's triad of small bowel obstruction, gallstone outside the gallbladder [Figure 2], and pneumobilia (presence of contrast and air in the bile duct) were also noted in the CT film.
|Figure 1: 320 slice CT-abdomen with contrast showing two stones inside the jejunum in the upper two images and a stone inside the gallbladder in the lower two images|
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|Figure 2: The lower left CT abdomen with contrast images clearly showing two stones inside the jejunum which has been encircled in red colour|
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After proper preoperative assessment and optimization, she was taken up for open cholecystectomy, duodenal fistula closure, and enterolithotomy by a surgical gastroenterologist.
Laparotomy was done with Makuuchi incision, a large stone (2 cm) was seen inside the gallbladder, and a large cholecystoduodenal fistula of size 3 cm × 3 cm and two stones of size about 4 cm × 3 cm were noted in the distal jejunum causing obstruction and free fluid present.
Cholecystoduodenal fistula was disconnected and cholecystectomy was done. In addition, duodenal vent was closed with interrupted 2-0 vicryl sutures. Stones [Figure 3] were extracted by enterotomy and closed in two layers. Bilateral diffusion tensor was kept for continuous drainage and feeding jejunostomy was done. Wound closed in layers. Histopathological examination of the gallstones [Figure 3] revealed dark brown, oval-shaped with smooth-surfaced three stones weighing around 23.3 g which consists of oxalate, phosphate, calcium, nonoxalate calcium, bilirubin, and cholesterol.
|Figure 3: Post-OP pictures of the stones (1) A tiny stone (2 cm) marked as 1 has been removed from the gallbladder (2) two stones (size of 4 cm × 3 cm) marked as 2 in the picture have been removed from the jejunum|
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The abdominal bilateral drain was removed on the postoperative day 5. The patient recovered well from surgery and oral liquids were started on the 3rd postoperative day. She was discharged from hospital on 9th postoperative day with the feeding jejunostomy tube in situ and advised to have regular follow-up with a surgical gastroenterologist. We have a plan of removing feeding jejunostomy tube in 8 weeks. The patient is doing well with no complications.
| Discussion|| |
Gallstone ileus is a very rare disease, which occurs as a complication of gallstones, and constitutes 1%–4% of the causes of mechanical intestinal obstruction. It occurs in elder patients with a high rate of morbidity and mortality.
In 1654, Bartholin first named gallstone ileus and defined it as a mechanical obstruction due to impaction of one or more large gallstones within the gastrointestinal (GI) tract. A gallstone can enter the GI tract through a fistula between an inflamed (gangrenous) gallbladder and the GI tract. Pressure necrosis by the gallstone against the biliary wall then causes erosion and fistula formation. Most common locations of gallstone impaction are the terminal ileum and the ileocecal valve because of the anatomical small diameter and less active peristalsis. Other rare locations of impaction include the jejunum, the ligament of Treitz, stomach, and far less commonly the duodenum and colon.
The diagnosis is difficult to be made based only on symptoms of nausea, vomiting, abdominal distension, and pain, although many patients have a history of cholecystolithiasis. On plain abdominal radiography, classical signs of Rigler's triad (pneumobilia, dilated intestinal loops, aberrant gallstone) aid diagnosis. A preoperative diagnosis of GI is feasible in only 50%–60% of patients. In 50% of cases, definitive diagnosis is made at laparotomy. With imaging studies (CT and magnetic resonance imaging) the preoperative diagnosis is easier. Abdominal CT has an overall sensitivity, specificity and diagnostic accuracy of 93%, 100%, and 99%, respectively. However, gallstones may be missed on CT as they are not always hyperdense.
Emergency surgery is required once the diagnosis of gallstone ileus has been made. There are various surgical options: (1) enterotomy with stone extraction only (more common), (2) enterotomy, stone extraction, cholecystectomy, and fistula closure, (3) bowel resection only, and (4) bowel resection with fistula closure. The surgical approach is based on the clinical condition of the patient. Usually, the patients with GI are elderly with significant comorbidities and clinically unstable on admission, due to ileus. For such patients, enterolithotomy alone appears sufficient.
Nonsurgical treatment of gallstone ileus has been suggested, including endoscopic removal and shockwave lithotripsy, but this depends on the location of the obstruction. Furthermore, the prognosis of gallstone ileus is poor and worsens with age.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]