Journal of Digestive Diseases
BlackwellPublishingAsiaMelbourne,AustraliaCDDChineseJournalofDigestiveDiseases1443-96111751-2980©2009TheAuthorsJournalcompilation©2009ChineseMedicalAssociationShanghaiBranch,ChineseSocietyofGastroenterologyandBlackwellPublishingAsiaPtyLtd. XXX CaseReport
Recurrent gallstone ileus: time to change our surgery?
J Edward F FITZGERALD,*
Lucy A FITZGERALD,* Charles A MAXWELL-ARMSTRONG* & Adam J BROOKS**Department of Gastrointestinal Surgery, and
Medical Education Unit, University of NottinghamMedical School, Nottingham University Hospital, Nottingham, UK
Gallstone ileus was ﬁrst described by Bartolin in 1654,and it remains an uncommon cause of small bowelobstruction. Optimal surgical management is con-troversial. Gallstone ileus arises when an inﬂamedgallbladder adheres to adjacent bowel, forming abiliary-enteric ﬁstula which allows stones to pass intothe intestinal tract. This commonly occurs at theduodenum, although colonic connections have also beendescribed.
Rarely, the stone may give rise to Bouveret’ssyndrome, where impaction in the duodenum causessymptoms of gastric outlet obstruction.
Of increasing importance due to greater life expect-ancy, gallstone ileus is a disease of the elderly and ismore frequent in women. While it accounts for 1–3%of cases of mechanical small bowel obstruction over-all, this increases with age to represent 25% in over the65s.
In this group mortality is high at 25%, largely attributable to associated medical comorbidities.Recurrence is infrequent, with only 5% of patientsexperiencing further episodes.
In this article we present a rare case of recurrence, andin the light of this we discuss the differing surgicalstrategies available for treatment of the primary presentation.
A 71-year-old man was admitted with a short history of abdominal pain and vomiting. He had previously been diagnosed with gallstones, ischemic heart diseaseand an abdominal aortic aneurysm (AAA). Examinationrevealed a soft, distended abdomen with tenderness inthe right upper quadrant. His distal pulses were normal.His observations were stable, allowing an abdominalcomputed tomography (CT) angiogram to be performed(Fig. 1). This conﬁrmed an infra-renal AAA measuring 5.4 cm with no leak. However, dilated loops of ﬂuid-filled small bowel together with an intraluminal calciﬁedlesion suggested a diagnosis of gallstone ileus. A secondlarge gallstone was visualized within the gallbladder (Fig. 2). The patient underwent emergency laparotomy where agallstone was removed from the jejunum. The bowel was otherwise healthy. He subsequently made anuncomplicated recovery and was discharged home with a plan for elective cholecystectomy.
Correspondence to: JEF FITZGERALD, Medical Education Unit,University of Nottingham Medical School, Derby Road, Nottingham, NG7 2UH, UK. Email: edwardﬁtzgerald@doctors.org.uk
2009 The AuthorsJournal compilation
2009 Chinese Medical AssociationShanghai Branch, Chinese Society of Gastroenterology andBlackwell Publishing Asia Pty Ltd.
Figure 1.Abdominal computed tomography angiogramshowing infra-renal abdominal aortic aneurysm, dilatedsmall bowel loops and a gallstone in the small bowel.