Gallstone Ileus With Jejunum Perforation Managed With Laparoscopic-Assisted Surgery: Rare Case Report and Minimal Invasive Management

Gallstone ileus is an uncommon complication of cholelithiasis. Most patients affected by gallstone ileus are elderly and have multiple comorbidities. Symptoms are vague and insidious, which may delay the correct diagnosis for days. Here we are reporting an uncommon complication of gallstone ileus. We report on a 70-year-old man with small bowel obstruction at the jejunum due to an impacted stone, which led to necrosis and perforation of the proximal bowel wall. Laparoscope-assisted small bowel resection with enterolithotomy was used to successfully treat the patient''s perforation and obstruction. His recovery was uneventful. Gallstone ileus commonly presents with bowel obstruction, but intestinal perforation occurs very rarely. A laparoscopic approach can provide both diagnostic and therapeutic roles in management.Key words: Gallstone ileus, Jejunal perforation, Laparoscopic surgery, Intestinal obstructionGallstone ileus is characterized by intestinal obstruction due to intraluminal impaction of one or more gallstones. It is an uncommon but serious complication of cholelithiasis and accounts for 1% to 3% of cases of patients who undergo surgery for bowel obstruction.^1,2 A cholecystoduodenal fistula is the most common tract.³ Most patients are elderly and female, and the average age range is 65 to 75 years. In spite of treatment, the mortality rate ranges from 10% to 20%.^4,5Gallstone ileus with proximal small bowel perforation is rare, and fewer than 10 cases have been reported in the medical literature.⁶ We describe a case of gallstone ileus with jejunum perforation that was successfully treated with laparoscopically assisted surgery.     

A single centre case series of gallstone sigmoid ileus management

Aims/IntroductionGallstone sigmoid ileus is a rare condition that presents with symptoms of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon. This arises because of three primary factors: cholelithiasis causing a cholecystoenteric fistula; a gallstone large enough to obstruct the bowel lumen; and narrowing of the bowel.We describe 3 patients treated in a district general hospital over a 3-year period, and discuss their management.MethodsCases were retrospectively analysed from a single center between 2015 and 2017 in line with the SCARE guidelines.Results3 patients – 2 female, 1 male. Age: 89, 68, 69 years. 2 cholecystocolonic fistulae, 1 cholecystoenteric (small bowel) fistula.Patient 1: Unsuccessful endoscopic attempts to retrieve the (5 × 5 cm) gallstone resulted in surgery. Retrograde milking of the stone to caecum enabled removal via modified appendicectomy.Patient 2: Endoscopy and lithotripsy failed to fragment stone. Prior to laparotomy the stone was palpated in the proximal rectum enabling manual extraction.Patient 3: Laparotomy for gallstone ileus failed to identify a stone within the small bowel. Gallstone sigmoid ileus then developed. Conservative measures successfully decompressed the large bowel 6 days post-operation.ConclusionsThis is the first case series highlighting the differing strategies and challenges faced by clinicians managing gallstone sigmoid ileus. Conservative measures (including manual evacuation), endoscopy, lithotripsy and surgery all play important roles in relieving large bowel obstruction. It is essential to tailor care to individual patients’ needs given the complexities of this potentially life threatening condition.     

Gallstone ileus associated with impaction at Meckel’s diverticulum: Case report and literature review

Gallstone ileus due to erosion of one or more gallstones into the gastrointestinal tract is an uncommon cause of small bowel obstruction. The site of impaction is usually distal ileum, and less commonly the jejunum, colon, duodenum, or stomach. We report a rare case of gallstone ileus with impaction at the proximal small bowel and at a Meckel’s diverticulum (MD) in a 64-year-old woman managed with laparoscopic converted to open small bowel resections. Patient was discharged home in stable condition and remained asymptomatic at 6-mo follow up. We review the current literature on surgical approaches to MD and gallstone ileus. Diverticulectomy or segmental resection is preferred for complicated MD. For gallstone ileus, simple enterolithotomy or segmental resection are the most the most favored especially in older co-morbid patients due to lower mortality rates and the rarity of recurrent gallstone ileus. In addition, laparoscopy has been increasingly reported as a safe approach to manage gallstone ileus.     

Gallstone ileus presenting as intussusception: A case report

BackgroundGallstone ileus is a complication of acute cholecystitis that accounts for 25% of bowel obstruction cases in the elderly. To our knowledge, only one other case of gallstone ileus presenting as intussusception has been reported in the literature, and involved non-operative management with an unfavorable outcome.Case presentationHere we report the case of 69 year old woman presenting with symptoms of acute small bowel obstruction with a surgical history significant for cholecystectomy 30 years prior. Computed tomographic imaging showed a target sign in the small bowel consistent with intussusception, but intraoperative diagnosis revealed this to be a gallstone. A simple enterolithotomy was conducted and the patient has since been symptom free.DiscussionGallstone ileus has a high mortality rate (12–17%) and is an important differential diagnosis to consider, especially as the elderly population throughout the world continues to grow.ConclusionAs radiographic features of gallstones are variable we suggest maintaining a high index of suspicion for gallstone ileus in any elderly patient presenting with SBO, even with a seemingly contradictory surgical history.     

Gallstone ileus: One-stage surgery in an elderly patient: One-stage surgery in gallstone ileus

INTRODUCTIONGallstone ileus (G.I.) is a mechanical bowel obstruction due to impaction of a large gallstone within the bowel and represents an uncommon complication of cholelithiasis. It accounts for 1–4% of all cases of mechanical bowel obstruction, up to 25% in patients over 65 years of age.PRESENTATION OF CASEA 75 year old male patient was referred to our hospital in March 2009 with clinical signs of bowel obstruction (abdominal pain and distension, post-prandial vomiting, absolute constipation) during the previous 3 days. A plain abdominal film demonstrated dilated bowel loops, air fluid levels and an image of a stone in the inferior left quadrant. Afterwards, diagnosis of Gallstone ileus was made by means of ultrasonography and colonoscopy. The patient underwent emergent laparotomy and a cholecysto-transverse colon fistula was observed. One-stage procedure consisting of enterolithotomy, cholecystectomy and fistula repair was performed. The post-operative course was complicated by a dehiscence of the colic suture with acute peritonitis. Therefore a colostomy was performed, followed by rapid recovery of general clinical conditions.DISCUSSIONSurgical treatment for G.I. by cholecysto-enteric fistula is still controversial. Enterolithotomy alone is best suited in all elderly patients with significant comorbidities. One-stage procedure – enterolithotomy, cholecystectomy and fistula repair – should be reserved for young, fit and low risk patients. In our case, mechanical obstruction was associated with a severe cholecystitis with a large fistula between gallbladder and transverse colon.CONCLUSIONA “radical” surgical option could certainly be characterized by a significant morbidity.     

Recurrent small bowel obstruction after laparoscopic surgery for gallstone ileus

Gallstone ileus is an uncommon cause of small bowel obstruction. A patient presenting with gallstone ileus was managed in our department by laparoscopic enterolithotomy. Postoperatively, the patient developed recurrent small bowel obstruction due to the presence of a second gallstone. It is therefore important to exclude the possibility of multiple gallstones at the initial operation.     

Gallstone ileus associated with impaction at Meckel's diverticulum:Case report and literature review

Gallstone ileus due to erosion of one or more gallstones into the gastrointestinal tract is an uncommon cause of small bowel obstruction. The site of impaction is usually distal ileum, and less commonly the jejunum, colon, duodenum, or stomach. We report a rare case of gallstone ileus with impaction at the proximal small bowel and at a Meckel's diverticulum(MD) in a 64-yearold woman managed with laparoscopic converted to open small bowel resections. Patient was discharged home in stable condition and remained asymptomatic at 6-mo follow up. We review the current literature on surgical approaches to MD and gallstone ileus. Diverticulectomy or segmental resection is preferred for complicated MD. For gallstone ileus, simple enterolithotomy or segmental resection are the most the most favored especially in older co-morbid patients due to lower mortality rates and the rarity of recurrent gallstone ileus. In addition, laparoscopy has been increasingly reported as a safe approach to manage gallstone ileus.     

Evaluation and surgical management of the gallstone ileus. A single center experience

Gallstone ileus representing 1-4% of all bowel obstructions cholelithiasis. Impaction of a gallstone in the human of the bowel is a surgical emergency. Relief of the obstruction is the treatment of choice, but controversy exists regarding the repair of the fistula and cholecystectomy. Our experience in the management of gallstone ileus is presented in the following article.     

Laparoscopic Enterolithotomy Is a Valid Option to Treat Gallstone Ileus

Gallstone ileus is a well-recognized clinical entity. It usually affects elderly female patients, and very often diagnosis can be delayed resulting in high morbidity and mortality. An abdominal x-ray and computed tomographic (CT) scan of the abdomen may show classical radiological features of small bowel obstruction, pneumobilia, and an ectopic gallstone. Laparotomy and enterlithotomy with or without definite biliary surgery is an established treatment. Since 1992, many cases of laparoscopic-assisted enterolithotomy have been reported. Only a few cases of a totally laparoscopic approach have been documented. We present the case of a 75-year-old lady who presented with features of intestinal obstruction. A plain x-ray of the abdomen and a CT scan confirmed the classical features of gallstone ileus. A totally laparoscopic enterolithotomy was performed using 6 ports. A 6-cm gallstone was retrieved through a longitudinal enterotomy. The transverse closure of the enterotomy was performed with intracorporeal suturing, resulting in an uneventful postoperative recovery. We suggest that a CT scan helps in the early diagnosis of the cause of intestinal obstruction, and totally laparoscopic enterolithomy with intracorporeal enterotomy repair is a valid, safe option.     

Gallstone ileus in a patient with amyotrophic lateral sclerosis: A case report

Introduction and importanceGallstone ileus is a rare disease that most commonly occurs in elderly females with a history of cholelithiasis. It has not been previously associated with Amyotrophic Lateral Sclerosis (ALS); a neurodegenerative disease that primarily affects the motor neurons at the spinal and bulbar levels. Autonomic malfunction, in particular, gastrointestinal dysfunction has been documented in ALS patients which may predispose this population to the development of gallstones and gut dysmotility.Case presentationIn this paper, we report a case of gallstone ileus in a patient with diagnosed ALS. We performed an exploratory laparotomy, enterolithotomy, and an open cholecystectomy with takedown/closure of a cholecystoduodenal fistula. The patient had a relatively uncomplicated postoperative course and was discharged from the hospital on postoperative day nine.Clinical discussionDelays in gastric emptying and colonic transit times in ALS patients may pose a risk for the development of gallstones and the potential impaction of a gallstone ileus in patients who are left untreated. Multifactorial evaluation of this patient population is necessary when assessing a potential causal pattern of gallstone ileus in patients with significant comorbidities.ConclusionWe present an unusual pathology without an established incidence, which has pertinent multidisciplinary implications. The suspicion of ALS as a potential cause for the development of a gallstone ileus is relevant and essential in the diagnostic workup for an elderly patient who develops a small bowel obstruction with multi-comorbidities.     

Migrating gallstone: from Bouveret's syndrome to distal small bowel obstruction

Gallstone ileus is an uncommon cause of small bowel obstruction. When the gallstone lodges inside the duodenum and causes gastric outlet obstruction, it is termed Bouveret's syndrome. However, it is rather unusual to seen the evolution of a migrating gallstone (from duodenum to distal small bowel) in a patient during the same hospital admission. We report a case of gallstone ileus from the initial presentation of gastric outlet obstruction to the development of distal small bowel obstruction within the same hospital admission, and its total laparoscopic treatment.     

Bowel obstruction and perforation due to a large gallstone. A case report

IntroductionGallstone bowel obstruction is a rare form of mechanical ileus usually presenting in elderly patients, and is associated with chronic or acute cholecystitis episodes.Case presentationWe present the case of an 80 year old female with abdominal pain, inability to defecate and recurrent episodes of diarrhea for the past 8 months. CT examination uncovered a cholecystoduodenal fistula along with gas in the gall bladder and the presence of a ≥2 cm gallstone inside the small bowel lumen causing obstruction. Patient was admitted to the operating room, where a 3.2 cm gallstone was located in the terminal ileus. A rupture was found in the antimesenteric part of a discolored small bowel segment, approximately 60 cm from the ileocaecal valve, through which the gallstone was recovered. The bowel regained its peristalsis, and the rupture was debrided and sutured. Patient was discharged uneventfully on the 6th postoperative day.DiscussionGallstone ileus is caused due to the impaction of a gallstone inside the bowel lumen. It usually passes through a fistula connecting the gallstone with the gastrointestinal tract. It can present with nonspecific or acute abdominal symptoms. CT usually confirms the diagnosis, while there are a number of treatment options; conservative, minimal invasive and surgical. Our patient was successfully relieved of the obstruction through recovery of the gallstone using open surgery, with no repair of the fistula.ConclussionAlthough rare, gallstones must be suspected as a possible cause of bowel obstruction, especially in elderly patients reporting biliary symptoms.     

The operative management of gallstone ileus

INTRODUCTION

Gallstone ileus is an uncommon entity, which accounts for 1–4% of all presentations to hospital with small bowel obstruction and for up to 25% of all cases in patients over 65 years of age. Despite medical advances over the last 350 years, gallstone ileus is still associated with high rates of morbidity and mortality. The management of gallstone ileus remains controversial. Whilst open surgery has been the mainstay of treatment, more recently other approaches have been employed, including laparoscopic surgery and lithotripsy. However, controversy persists primarily in relation to the extent of surgery performed.

MATERIALS AND METHODS

A literature review was performed in an attempt to discover the optimal surgical treatment of gallstone ileus, particularly the timing of biliary surgery. Published articles were identified from the medical literature by electronic searches of Pubmed and Ovid Medline databases, using the search terms ‘gallstone ileus’, ‘gallstone/intestinal obstruction’ and ‘gallstone/bowel obstruction’. The related articles function of the search engines was also used to maximise the number of articles identified. Relevant articles were retrieved and additional articles were identified from the references cited in these articles.

RESULTS AND CONCLUSIONS

The literature on gallstone ileus is composed entirely of retrospective analysis of small numbers of patients accumulated over many years. The question as to whether one stage or interval biliary surgery should be performed remains unanswered and it is unlikely that further case series will help decision making in the management of gallstone ileus. Whilst many authors conclude that enterolithotomy alone is the best option in most patients, a one-stage procedure should be considered for low-risk patients.     

A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy

INTRODUCTIONGallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported.PRESENTATION OF CASEWe report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy.DISCUSSIONLaparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract.CONCLUSIONEndoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery.     

Gallstone ileus associated with cholecystogastric fistula: Case report,diagnosis and surgical treatment

IntroductionGallstone Ileus is a rare complication of cholelithiasis, associated with multiple episodes of cholecystitis, with the formation of adhesions and fistulas between the gallbladder and adjacent organs. Its diagnosis is difficult, requiring complementary imaging tests such as computed tomography or radiography.Presentation of caseFemale patient, with intestinal obstruction for 7 days, associated with abdominal pain and previous episodes of pain in the right hypochondrium for 3 months. Abdominal CT scan identified aerobilia, gallstone impacted in the ileocecal valve and small loop dilatation, in addition to a probable cholecystogastric fistula. Opted for exploratory laparotomy, enterolithotomy and fistula correction in one surgical time.DiscussionGallstone ileus is rare among the complications of cholelithiasis, in addition to the fact that cholecystogastric fistula is associated with gastric pylorus obstruction and not impaction on the ileocecal valve. Imaging tests are useful to complement the diagnosis, and if Rigler's triad is present, the suspicion of gallstone ileus is increased. The presence of fistula between the gallbladder and stomach presents a frequency between 0 and 13.3%. There is no gold standard treatment for gallstone ileus, but surgery options for each type of patient and severity level.ConclusionThere is no definitive protocol for optimal surgical treatment for biliary ileus, but the possibility of enterolithotomy associated with cholecystectomy and fistula correction can be evaluated in selected patients.     

A peculiar cause of bowel obstruction

INTRODUCTIONGallstone disease is one of the most common surgical problems necessitating intervention. It is estimated that approximately 15% of people in the western world will develop gallstones. Of these patients, 35% of patients initially diagnosed with gallstones will later develop a complication which will eventually result in cholecystectomy.²One of these complications is gallstone ileus, which is a rare complication associated with high morbidity and mortality, and the diagnosis is often missed.³PRESENTATION OF CASEA 66 year old female presented with an acute onset of “colicky” abdominal pain accompanied with vomiting. She had known gallstones diagnosed previously by ultrasound. Her abdomen was generally tender with guarding of the right hypochondrium and absent bowel sounds.DISCUSSIONGallstone ileus accounts for 0.5–4% of all cases of small bowel obstruction, and typically affects females over the age of 65.3, 4 The pathophysiological basis of the disease involves fistulation of the gallstone through the wall of the gallbladder into the bowel, where it becomes impacted and leads to obstruction. Mortality of the condition is not sufficiently reported, but surgical intervention in itself conveys significant morbidity, and mortality has been reported to be 18%.3, 9CONCLUSIONWe report a single large gallstone, which we believe to be one of the largest documented in recent literature, resulting in gallstone ileus. We also present a brief synopsis of the diagnosis and management of the condition, which although rare, should be considered by the astute surgical trainee.     

Laparoscopic management of gallstone ileus.

Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in perioperative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed. We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively. Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.     

Gallstone ileus: report of a case successfully treated by a laparoscopically-assisted enterolithotomy

Gallstone ileus is an unusual cause of small bowel obstruction that occurs more frequently in elderly patients. The diagnosis is always very challenging and in most of cases this rare complication is misdiagnosed before surgery. The Authors report on a 81-year-old woman with small bowel obstruction who was laparoscopically diagnosed with gallstone ileus and successfully treated by a laparoscopically-assisted enterolithotomy.     

Resolution of Gallstone Ileus with Spontaneous Evacuation of Gallstone: A Case Report

Gallstone ileus is an infrequent complication of cholelithiasis. The formation of a fistula between the gallbladder and duodenum may allow a gallstone to enter the gastrointestinal (GI) tract. Gallstone ileus generally occurs in the elderly patients and is associated with significant mortality. Spontaneous resolution of gallstone ileus after passage of gallstone per rectally, though rare, has been reported Farooq et al. (Emerg Radiol 4(6):421–423, 2007). We describe a 60-year-old woman who presented with a 3-day history of vomiting, pain, distension and constipation .Radiological investigations revealed dilatation of small bowel loops with multiple air fluid levels with a large lamellated radio-opaque density measuring 4.4 cm × 4 cm seen in the right iliac fossa. A possibility of gallstone ileus was kept. Because of co-morbid conditions (post-myocardial infarct with cardiac failure), surgery could not be done and patient was kept on conservative management. Three days later patient had sudden relief of her symptoms after passing a large calculus per rectally suggesting a spontaneous evacuation of gallstone. This case highlights the possibility of spontaneous resolution of gallstone ileus after the passage of gallstone. It has been reported in stones less than 2.5 cm. However, to the best of our knowledge, this is the first time in which a large stone measuring 4 cm × 3.8 cm passed spontaneously.     

Staged and complete laparoscopic management of cholelithiasis in a patient with gallstone ileus and bile duct calculi

BACKGROUND: Gallstone ileus is an uncommon cause of small bowel obstruction, and its incidence peaks in elderly women. Although enterolithotomy has been accomplished laparoscopically, often using a laparoscopically assisted approach, controversy persists as to the indication, timing, and surgical approach to a cholecystectomy with closure of the cholecystoduodenal fistula. METHODS: We present the case of a 63-year-old woman with symptomatic cholecystolithiasis who presented with acute gallstone ileus and underwent an emergency laparoscopic enterolithotomy. Hypotonic duodenography during the follow-up period demonstrated a cholecystoduodenal fistula and previously unsuspected stones in the bile duct. The patient underwent an elective laparoscopic cholecystectomy with repair of the fistula, a concomitant bile duct exploration, choledocholithotomy, and primary bile duct closure. RESULTS: The patient enjoyed an uneventful recovery, and was discharged home on postoperative day 5 after her initial emergency surgery. Her recovery after the subsequent elective surgery was more expeditious, with a discharge from hospital on postoperative day 2 and a return to office employment 2 weeks later. CONCLUSION: In the good-risk patient, staged laparoscopic management of gallstone ileus and the associated cholecystoduodenal fistula is feasible and appears to be safe. In such patients, imaging of the biliary tree is essential to detect silent choledocholithiasis, which also may be managed concomitantly and safely by the laparoscopic approach.