The onestage procedure of combining biliary surgery should be offered only to highly selected patients with absolute indications for biliary surgery at the time of presentation in a patient fit for tolerating both operations 9. It accounts for 1%4% of all bowel obstructions and is more common in elderly patients. Diagnosis and treatment of biliary fistulas in the. Gallstone ileus is a rare cause of gastrointestinal obstruction, more frequent in elderly patients, whose treatment is essentially surgical, although some parasurgical and miniinvasive possibilities exist, allowing the solution of such obstructive condition in a completely noninvasive way. Erosion through the wall of the gallbladder into the alimentary canal is the common path by which a biliary calculus may gain entrance to the gut. Radiological findings in biliary fistula and gallstone ileus. Our patients history of gallbladder disease and the development of imaging techniques played a key role in. After four days of conservative treatment she underwent scheduled laparotomy with enterolithotomy and stone extraction. Ultimately the management of the patient was not compromised by the. Gallstone ileus analysis of radiological findings in 27. Although the operation was uneventful, immediately after that in the recovery.
Recently nemir 9 reported 8 cases of gallstone ileus treated surgically, representing 1. Gallstone disease is the most common disorder affecting the biliary system. They can affect either the biliary or the gastrointestinal tract and are usually classified as primary or secondary. It is done surgically using open or laparoscopic approach and rarely, when stones are impacted in the colon, endoscopically. Cholecystoduodenal fistula is the most common fistula type occurring in about 70% of patients due to the proximity of the duodenum, while cholecystocolonic and. Rather they are typically asymptomatic or occur in association with common digestive complaints consistent with gastric or biliary tract disease.
The preferred treatment option is to mechanically remove the. Laparoscopic surgery is a therapeutic option for the treatment of primary biliary fistulas. She had a past medical history of thyroidectomy and mild heart failure. Primary biliary cholangitis pbc, previously known as primary biliary cirrhosis, is an autoimmune disease of the liver. Another rare complication of cholelithiasis is mirizzis syndrome, characterized by extrinsic compression of the bile duct by the infundibulum of the gallstone or cystic duct 12, which may culminate in. Most cholecystoduodenal fistulae do not result in gallstone ileus see fig. It occurs after the spontaneous formation of a biliary enteric fistula, most commonly with the duodenum, less commonly with the colon, and very rarely with the stomach. Gallstone ileus is an uncommon cause of a mechanical small bowel obstruction. Typically as a result of the formation of cholecystoduodenal fistula, surgical removal of the gallstone is the mainstay of treatment in order to relieve the intestinal obstruction. Gallstone ileus is a rare mechanical bowel obstruction caused by the transition of a gallstone in the gastrointestinal tract through a biliaryenteric fistula, or following endoscopic retrograde cholangiopancreatography ercp, which occurs in 1 to 3% of all cases of mechanical ileus.
The first laparoscopic cholecystectomy, performed by prof. Gallstone ileus accounts for only about % of cases of mechanical. Biliary stones reach the intestinal tract through a biliodigestive fistula in 8085% and on natural way in 1520%. In both cases sonography revealed a small amount of air. Gallstone ileus represents 4% of the causes of bowel obstruction in the. The preoperative diagnosis of biliary ileus was correctly made by us in two cases 87 and 80yearold females referred to us studies because of nonspecific abdominal symptoms and to rule out possible acute appendicitis, respectively. Subsequently, large stones within the gallbladder cause pressure necrosis, resulting. The roentgen diagnosis of gallstone ileus radiology. Computed tomography ct revealed gsi of the transverse colon with a closedloop large bowel. B axial and c coronal ct of the gallstone in the distal ileum. Evolution of enterobiliary fistula following gallstone. Gallstone ileus is a heterogeneous and highly morbid condition that suffers from a lack of consensus regarding the timing and approach to management of the biliary tree and associated fistula. Although the disorder is a rare cause of small bowel obstruction 1% to 2%, it has been reported to cause up to 25% of cases of nonstrangulated small bowel obstruction in patients over 65 years of age. The diagnosis of gallstone ileus entails a clinical challenge, especially in older patients in whom it may be easily overlooked.
Gallstone ileus is a mechanical obstruction caused by the impaction of one or more gallstones within the lumen of any part of the gastrointestinal tract. Here, we describe a case of 67 year old woman who presented with non specific abdominal symptoms and on evaluation was found to have small bowel obstruction caused by wedging of a large gallstone at. Gallstone ileus in the absence of biliary fistula jama. Biliary fistulas are rare complications of gallstone. We present the case of an 83yearold caucasian woman who had three episodes of gallstone ileus, each of which was managed with simple enterotomy. However, a choledochoenteric fistula and, when the stones are small enough, the ampulla of vater also serve as pathways. In our study, after reporting two cases of biliary ileus managed by our surgical division, we will. According to the literature, approximately 4050% of patients eventually diagnosed with gallstone ileus have a history of recent bouts of biliary colic, jaundice or acute cholecystitis 1, 2. Plainfilm findings were unremarkable in one patient, smallbowel obstruction was detected in the latter. Disease spectrum and use of cholecystolithotomy in. It is a rare complication of chronic cholecystitis 7 and occurs when a gallstone passes through a fistula between the gallbladder and small bowel before becoming impacted at the ileocecal valve. Gallstone ileus also known as biliary ileus, a rare complication of cholelithiasis, is defined as a mechanical intestinal. A 73yearold woman presented with 5day history of colicky abdominal pain, distension, vomiting, and signs of peritonism in the lower abdomen. Further history revealed a paired biliarypancreatic stent insertion three years prior for ascending cholangitis and a longstanding asymptomatic right inguinal hernia.
An analysis of 104 cases of gallstone ileus in 102 patients is presented. A bilioenteric fistula, most commonly between gallbladder and duodenum, allows the passage of a large gallstone. A 64 yearsold female patientreferred to our hospital for further treatmentof gallstone ileusdiagnosed at another hospital. Gallstone ileus treated with nonsurgical conservative. The average age of occurrence is about 70 years old. An abdominal radiograph showed dilated loops of small bowel, air in the biliary tree and gall bladder figure, thick arrows, and a peripherally radioopaque stone in the bowel figure, thin arrow. Management of gallstone ileus pavlidis 2003 journal. Postcholecystectomy partial biliary stricture leading to. Early preoperative diagnosis could reduce morbidity and mortality. The diagnosis is difficult and may be delayed until operation. However, the presence of a biliary fistula and a history of stones in the gallbladder made the gallstone ileus diagnosis most probable. Gallstone ileus occurs when a large gallstone erodes through the gallbladder wall as a result of inflammation and pressure necrosis into the small bowel via a cholecystoenteric fistula.
The imaging also demonstrated several typical features for the pathologies in question. Pneumobilia, the presence of air in the biliary tree, may be noted on plain films of 30% to 50% of patients with gallstone ileus fig. Two clinical reports are analyzed and the various surgical procedures critically evaluated. In a previous communication 1 high obstruction in the dog was found to be compatible with life as long as a month if the biliary, pancreatic and duodenal secretions were shortcircuited below the point of obstruction. An 88yearold man presented to the emergency department with abdominal pain and distension. Abstract gallstone ileus is a rare etiology of small bowel obstruction, occurring typically in the elderly population. Gallstone disease gsd has a wide spectrum of clinical presentations ranging from asymptomatic to lifethreatening forms like cholangitis, pancreatitis, gallstone ileus and gallbladder malignancy. The commonest entry of biliary calculi into the intestinal tract is by way of a cholecystoenteric fistula. A gallstone ileus, in the absence of a previous communication between intestine and biliary tree, is, however, a rare occurrence. Gallstone ileus is a rare complication of cholelithiasis and is one of the rarest forms of all mechanical bowel obstructions.
Small bowel perforation secondary to biliary stent. Philippe mouret in 1987 and described by himself in the first chapter of this book, was an event that revolutionized surgery in the past few decades. After going over the reference lists of all the fulltext articles, we carried out a manual search, identifying and collecting new items. Other, less common causes of pneumobilia include an incompetent sphincter of oddi, emphysematous cholecystitis, suppurative cholangitis, and. Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal obstruction. Echography and barium study of small bowel were made in 8. Discussion gallstone ileus constitutes less than 1% of cases of intestinal obstruction, and bouveret syndrome in turn accounts for 3% of gallstone ileus. The site of formation of the stone in one of these cases was a duodenal diverticulum 1 and in the other a blind duodenal stump following subtotal gastrectomy. Pdf biliary ileus, diagnostic and therapeutic approach. Introduction calculous disease of the biliary tract is the general term applied to diseases of the gallbladder and biliary tree that are a direct result of gallstones. Gallstone ileus is a rare cause of bowel obstruction and results from the passage of gallstones into the bowel.
We describe the case of a 90yearold female who presented with signs of a strangulated inguinal hernia. Biliary ileus a ct showing a cholecystoduodenal fi stula arrow. However, the simultaneous presentation of both in this patient provided a diagnostic puzzle for the surgical and radiological teams at our institution. Further slow damage to the liver tissue can lead to scarring, fibrosis, and eventually cirrhosis. Stones were principally located in distal small bowel loops stomach 3. Laparoscopic cholecystectomy is the current gold standard for. According to different authors, enterolithotomy alone is the best option for most patients with gallstone ileus. Gallstone or biliary ileus is a late complication of gallstone disease. The patient subsequently underwent an upper gastrointestinal endoscopy which demonstrated a large duodenal defect consistent with an enterobiliary fistula.
Biliary fistula and gallstone ileus are rarely found. Gallstone ileus is a rare disease that accounts for 14% of intestinal obstructions. Perforated closedloop obstruction secondary to gallstone. Six animals lived from twelve to thirtythree days, drank water and ate food occasionally, vomited from time to time, lost weight gradually and showed a gradual fall in blood. Corvera, joseph arturo reza, in blumgarts surgery of the liver, biliary tract and pancreas, 2volume set sixth edition, 2017. N2 gallstone ileus is the small bowel obstruction due to one or more biliary calculi stopped in the enteric lumen. The phenomenon of gallstone ileus was first described in 1654 by dr erasmus bartholin, a danish physician and mathematician, on a patient he examined at autopsy. The preferred treatment option is to mechanically remove the impacted stones. Gallstone ileus and small bowel diverticulosis are uncommon pathologies. It results from a slow, progressive destruction of the small bile ducts of the liver, causing bile and other toxins to build up in the liver, a condition called cholestasis. Abdominal ct demonstrated small bowel dilatation large arrow, figure 2, large calcifications within the small bowel and pneumobilia small arrow, figure 2 consistent with gallstone ileus. Biochemistry revealed a slightly elevated creactive protein level of 65 mmoll, but was otherwise unremarkable. Duodenal ileus is said in some way to render the biliary tract more liable to infection.
The presence of a biliaryenteric fistula is a prerequisite for passage of the stone into the small intestinea cholecystoduodenal fistula occurs most commonly. It occurs after the spontaneous formation of a biliaryenteric fistula, most commonly with the duodenum, less commonly with the colon, and very rarely with the stomach. The presence of a biliary enteric fistula is a prerequisite for passage of the stone into the small intestinea cholecystoduodenal fistula occurs most commonly. A 65yearold man presented to our emergency department with nausea, recurrent vomiting and colicky abdominal pain of 5 days duration. This older patient pathology is often associated with other comorbid medical conditions. It occurs because of the impaction of a particularly large gallstone in the small intestine. Pdf gallstone ileus is a mechanical intestinal obstruction caused due to impaction of a large gallstone within the. In a retrospective survey over the past 11 years there were 9 patients with gallstone ileus, all elderly mean age, 77 years, among 2242 cholecystectomies 0. Small bowel obstruction by gallstone ileus journal of. Gallstone ileus also known as biliary ileus, a rare complication of cholelithiasis, is defined as a mechanical intestinal obstruction due to a gallstone lodging in the intestinal lumen. Gallstone ileus gsi of the colon is an extremely rare entity with potentially serious complications including perforation. This entity was first described by the danish physician thomas bartholin in 1654 during an autopsy. The primary fistulas are related to the biliary lithiasis, while the secondary ones are related to surgical complications.