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Recurrent Gallstone Ileus, Time to Change Our Surgery?

Recurrent Gallstone Ileus, Time to Change Our Surgery?

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Published by Ed Fitzgerald
Recurrent gallstone ileus: time to change our surgery?
Fitzgerald JE, Fitzgerald LA, Maxwell-Armstrong CA, Brooks AJ.
J Dig Dis. 2009 May;10(2):149-51. doi: 10.1111/j.1751-2980.2009.00378.x.
Gallstone ileus was first described by Bartolin in 1654, and it remains an uncommon cause of small bowel obstruction. Optimal surgical management is controversial. Gallstone ileus arises when an inflamed gallbladder adheres to adjacent bowel, forming a biliary-enteric fistula which allows stones to pass into the intestinal tract. This commonly occurs at the duodenum, although colonic connections have also been described. Rarely, the stone may give rise to Bouveret's syndrome, where impaction in the duodenum causes symptoms of gastric outlet obstruction.

Of increasing importance due to greater life expectancy, gallstone ileus is a disease of the elderly and is more frequent in women. While it accounts for 1–3% of cases of mechanical small bowel obstruction overall, this increases with age to represent 25% in over the 65s. In this group mortality is high at 25%, largely attributable to associated medical comorbidities. Recurrence is infrequent, with only 5% of patients experiencing further episodes.

In this article we present a rare case of recurrence, and in the light of this we discuss the differing surgical strategies available for treatment of the primary presentation.
Recurrent gallstone ileus: time to change our surgery?
Fitzgerald JE, Fitzgerald LA, Maxwell-Armstrong CA, Brooks AJ.
J Dig Dis. 2009 May;10(2):149-51. doi: 10.1111/j.1751-2980.2009.00378.x.
Gallstone ileus was first described by Bartolin in 1654, and it remains an uncommon cause of small bowel obstruction. Optimal surgical management is controversial. Gallstone ileus arises when an inflamed gallbladder adheres to adjacent bowel, forming a biliary-enteric fistula which allows stones to pass into the intestinal tract. This commonly occurs at the duodenum, although colonic connections have also been described. Rarely, the stone may give rise to Bouveret's syndrome, where impaction in the duodenum causes symptoms of gastric outlet obstruction.

Of increasing importance due to greater life expectancy, gallstone ileus is a disease of the elderly and is more frequent in women. While it accounts for 1–3% of cases of mechanical small bowel obstruction overall, this increases with age to represent 25% in over the 65s. In this group mortality is high at 25%, largely attributable to associated medical comorbidities. Recurrence is infrequent, with only 5% of patients experiencing further episodes.

In this article we present a rare case of recurrence, and in the light of this we discuss the differing surgical strategies available for treatment of the primary presentation.

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Published by: Ed Fitzgerald on Jun 03, 2013
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149
 Journal of Digestive Diseases
2009
;
10;
149151doi: 10.1111/j.1751-2980.2009.00378.
BlackwellPublishingAsiaMelbourne,AustraliaCDDChineseJournalofDigestiveDiseases1443-96111751-2980©2009TheAuthorsJournalcompilation©2009ChineseMedicalAssociationShanghaiBranch,ChineseSocietyofGastroenterologyandBlackwellPublishingAsiaPtyLtd. XXX CaseReport 
Recurrentgallstoneileus JEFFitzgerald
etal.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 
INTRODUCTION
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.
1
Rarely, the stone may give rise to Bouveret’ssyndrome, where impaction in the duodenum causessymptoms of gastric outlet obstruction.
2
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.
3
In this group mortality is high at 25%, largely attributable to associated medical comorbidities.Recurrence is infrequent, with only 5% of patientsexperiencing further episodes.
4
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.
CASE REPORT 
 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.
 
150
 JEF Fitzgerald
et al.
 Journal of Digestive Diseases
2009;
 
10;
 
149–151
©
2009 The AuthorsJournal compilation
©
2009 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology and Blackwell Publishing Asia Pty Ltd.
Six days later he re-presented with diffuse abdominalpain and vomiting. On examination he had a soft, dis-tended abdomen with generalized tenderness. He wasadmitted for treatment of presumed postoperativeileus, however, he failed to settle and further radiologicalimaging was requested (Fig. 3). An abdominal CT revealed a 21-mm stone in the smallbowel. The stone previously noted in the gallbladder  was now missing. A diagnosis of recurrent gallstoneileus was made and at laparotomy a gallstone wasfound (Fig. 4) occluding the bowel at the suture linefrom his previous enterotomy. The patient subsequently made an uncomplicated recovery and was discharged8 days later.
DISCUSSION
Even in the presence of a bilary-enteric fistula, obstruc-tion is uncommon with up to 80% of stones being passed spontaneously.
5
However stones with a diame-ter 
2 cm are more likely to cause a true mechanicalobstruction, and the term gallstone ileus is thereforeconfusing.
6
Often the stone periodically obstructs as it passes through the small bowel, presenting with episodic symptoms of several days duration; a phenomenontermed ‘tumbling’ obstruction and one that frequently delays diagnosis. Non-specific symptoms along withan unremarkable physical examination between theseepisodes contribute to the delay. Complete obstructiontypically occurs when the stone lodges in the narrower terminal ileum. Rigler’s triad, the classic radiologicalsigns of air in the biliary tree, small bowel obstructionand a dystopic stone also allow for correct diagnosisbut have been reported in as few as 20% of patients. Two surgical strategies have been described for theprimary presentation: enterolithotomy alone, allowing a delayed cholecystectomy after an inflammation-freeperiod of 4–6 weeks (and therefore two-stage surgery) or enterolithotomy in combination with a cholecystectomy and fistula division (one-stage surgery).Controversy surrounds which of these is moreappropriate, and due to the infrequent nature of cases,little research exists to aid decision-making. Many surgeons advocate enterolithotomy alone as anemergency procedure, as it is faster and less technically demanding, with a very low risk of recurrence in theinterval before delayed cholecystectomy. Someresearchers argue that a subsequent cholecystectomy may not even be required in asymptomatic patients.
3
However, it is important to note the increased incidence
Figure 2.Abdominal computed tomography angiogramshowing a large gallstone retained in the gallbladder.Figure 3.Abdominal computed tomography showing acalcified lesion in a pelvic small bowel loop.Figure 4.The second gallstone removed at repeat laparotomy.

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