75-j?hrige Patientin mit persistierenden abdominellen Beschwerden und Erbrechen w?hrend einer Kreuzfahrt

Zusammenfassung Hintergrund: Bei älteren Patienten mit Gallensteinen muss bei unklaren abdominellen Schmerzen an einen Gallensteinileus gedacht werden, wie der folgende Fall zeigt. Fallbericht: Eine 75-jährige Patientin wurde wegen abdomineller Schmerzen, Übelkeit und Erbrechen stationär aufgenommen. An Vorerkrankungen waren eine gynäkologische Operation, ein arterieller Hypertonus und Asthma bronchiale bekannt. Diese Beschwerden wurden während einer Reise zuvor nicht adäquat erklärt. In der klinischen Untersuchung fielen insbesondere ein aufgeblähtes Abdomen sowie Zeichen des frühen Nierenversagens auf. Eine Abdomenübersichtsaufnahme zeigte das Bild eines Ileus mit multiplen Dünndarmspiegeln in Projektion auf den Mittelbauch. Die Sonographie und Computertomographie des Abdomens konnten dann den Nachweis einer Aerobilie, einer cholezystoduodenalen Fistel und eines ektopen Gallensteins im rechten Unterbauch erbringen. Die Patientin wurde daraufhin laparoskopisch assistiert enterolithotomiert. In einem zweiten Schritt wurden die cholezystoenterale Fistel erfolgreich saniert und eine Cholezystektomie durchgeführt. Die Rekonvaleszenz der Patientin war unauffällig. Schlussfolgerung: Der Gallensteinileus ist insgesamt selten, bei Patienten über 65 Jahren aber in etwa 25% Ursache einer Obstruktion des Dünndarms. Die Sonographie und das CT des Abdomens sind geeignete Methoden zur Diagnostik eines Gallensteinileus. Patienten mit Vorerkrankungen und Gallensteinileus sollten in einem zweizeitigen Vorgehen behandelt werden. Die Diagnose Gallensteinileus gehört in das differentialdiagnostische Repertoire des Internisten. Abstract Background: In elderly patients with gallstone disease, a gallstone ileus must be considered for unexplained abdominal pain. This is demonstrated in the following case report. Case Report: A 75-year-old female patient presented with a 72-hour history of abdominal pain, nausea and vomiting. The patient's abdomen was mildly distended, although soft and nontender with bowel sounds present. Plain radiographs and ultrasound investigation of the abdomen were compatible with small bowel obstruction. To clarify the etiology, an abdominal computed tomography scan was obtained. These examinations disclosed air in the biliary tree, dilated small bowel and an impacted intraluminal abnormality in the terminal ileum compatible with a gallstone. Operative intervention confirmed the presence of a 3 cm obstructing calculus in the terminal ileum that was removed by an enterolithotomy. A two-step cholecystectomy and closure of the cholecystoduodenal fistula were performed 8 weeks later. The patient's recovery was uneventful. Conclusions: Although rare in a general population, gallstone ileus accounts for 25% of nonstrangulated small bowel obstructions in patients over the age of 65. The radiographic picture and ultrasound of small bowel obstruction and the presence of air in the biliary tree are suggestive for the diagnosis of a gallstone ileus. In our patient, the computed tomography and ultrasound findings confirmed the diagnosis and led to a prompt and directed surgical intervention. In patients with comorbid factors a two-step approach with enterolithotomy in a first and cholecystectomy in a second operation should be the therapeutic strategy of choice.     

CT诊断胆肠瘘伴结石性肠梗阻9例分析

目的分析胆肠瘘伴结石性肠梗阻的CT影像特征,提高对该病的认识。方法回顾性分析经手术确诊的9例胆肠瘘伴结石性肠梗阻患者的CT影像资料。结果 9例患者CT征象为慢性胆囊炎合并胆囊周围炎表现:胆囊萎陷、变形,胆囊壁增厚,与周围结构分界不清,胆囊积气,1例合并肝内外胆道积气;9例均为小肠梗阻,其中6例为低位回肠梗阻,3例为空肠梗阻,梗阻小肠明显扩张积气、积液,伴有长短不等液平影征;9例梗阻胆结石直径1.9～2.6 cm,均呈环状高密度结节和肿块状改变。结论胆肠瘘伴结石性肠梗阻的CT影像特征具有特异性,CT是临床上最有价值的首选检查手段。     

Spontaneous biliary enteric fistulas

Biliary enteric fistulas usually occur as a complication of chronic cholelithiasis, may be difficult to document preoperatively, and often pose problems in surgical management. We reviewed 13 cases of spontaneous biliary enteric fistulas to identify methods of diagnosis, management, and complications. There was no specific set of clinical symptoms or signs that led to the diagnosis of a fistula. In six cases the diagnosis was made preoperatively by x-ray films showing pneumobilia, gallstone in the small bowel, or fistula. Initial surgical treatment included cholecystectomy in six cases, small bowel enterotomy and removal of gallstones in four, and vagotomy and antrectomy in one case. Two patients initially treated without operation were lost to follow-up. Eight complications occurred in six patients, and there were three deaths due to underlying cardiac disease. The morbidity and mortality of biliary enteric fistulas associated with chronic cholecystitis may be avoided by performing elective cholecystectomy when the patient is in optimal condition.     

Biliary-digestive fistula with gallstone ileus--a sonographic diagnosis

We demonstrate a patient with a fistula between the gallbladder and the small intestine combined with a gallstone ileus of the small bowel, diagnosed by ultrasound. Plain abdominal X-ray only revealed small bowel obstruction. All the typical diagnostic criteria of a biliodigestive fistula could be detected by ultrasound. The patient was operated and discharged a few days later. We demonstrate that biliodigestive fistulas can be diagnosed by ultrasound.     

An Evaluation of Buffered Versus Nonbuffered Acetylsalicylic Acid

About 3 per cent of all cases of acute small-bowel obstruction are caused by gallstones. However, gallstone obstruction of the colon is quite rare. If such colonic obstruction does occur, it is usually in the sigmoid colon.

It has been reported that gallstones which cause intestinal obstruction usually are 2.5 cm. in diameter or larger and reach the intestine through internal biliary fistulas. The authors report a case of gallstone obstruction of a normal sigmoid colon in which the gallstone entered the colon through a cholecystocolonic fistula.     

Recurrent enteric gallstone obstruction

Small bowel gallstone obstruction may recur, most often within a few days after surgery, due to an overlooked intraenteric stone or subsequent passage of another gallstone via the cholecystoenteric fistula. In the case reported herein there was a 6-month interval. A critical review of the radiologic signs of gallstone ileus is presented.     

Small bowel obstruction

Gallstone ileus is a rare complication of cholelithiasis, but an established cause of mechanical small bowel obstruction in elderly patients. It is associated with high morbidity and mortality as most patients are elderly with multiple comorbidities. Surgery of choice is enterolithotomy.     

Gallstone ileus: correlation between computed tomography, double-balloon enteroscopy and intra-operative findings

Gallstone ileus is an uncommon cause of small bowel obstruction, affecting mainly elderly patients. We report a case of gallstone ileus in an 88-year old female patient. The correlation between computed tomography, double-balloon enteroscopy and intra-operative findings is discussed, as well as treatment strategies.     

Uncommon and Unusual Gastrointestinal Causes of the Acute Abdomen: Computed Tomographic Diagnosis

There is a wide variety of uncommon and unusual gastrointestinal causes of acute abdominal and pelvic pain that may be prospectively diagnosed on computed tomography. We demonstrate 10 such diagnoses and briefly review the current computed tomography and clinical literature on intussusception occurring beyond early childhood, small bowel obstruction from internal hernia, cecal volvulus, intramural small bowel hemorrhage, Boerhaave's syndrome, gastrointestinal luminal foreign bodies, small bowel diverticulitis, hemoperitoneum secondary to abdominal tumor; gallstone ileus, and gallbladder torsion. Radiologists and clinicians need to be aware of these disorders, particularly with the widespread utilization of computed tomography (CT) in the management of patients with acute abdominal pain.     

Gallstone ileus: A rare cause of small intestine obstruction

Gallstone ileus is a very rare cause of mechanical bowel obstruction with often‐delayed presentation and nonspecific symptoms. Aerobilia is found in approximately 50% of patients with gallstone ileus.     

Problems of retained calculi in the bile duct.

A study of 68 patients subjected to re-surgery for residual or recurrent gallstones provided the following results: Among the 68 patients, the stones were recurrent in only 4, residual in 38, and uncertain but mostly suggesting residual in the other 26 cases. In many of the residual stone cases, the previous operations were cholecystectomy alone, retrospectively suggesting insufficient search for residual stones and other abnormalities in the biliary tract during the operations. Of the 4 recurrent stone cases, 3 of them showed bile duct stricture, papillary stenosis and idiopathic choledochus dilatation, respectively, while the remaining one, though free of any sign of bile stasis, had a gallstone formed around a silk-thread core. The indications for additional sphincteroplasty and biliodigestive anastomosis in re-operations were strictly consistent with those in the first operations. Seven operative fatal cases (10%) were mostly those of long persistent gallstones with serious hepatic failure. The follow-up studies in 53 patients showed as many as 51 cases returning to the preoperative occupation without any significant complaints. These results emphatically suggest that retained gallstone cases should be referred to surgical treatment as early as possible.     

Carcinoid tumor mistaken for persistent neurogenic bowel symptoms in a patient with paraplegia: a case report.

Neurogenic bowel in spinal cord injury (SCI) can present with constipation and diarrhea as ongoing problems. Usually, these manifestations are adequately controlled with modification in the bowel program. When these symptoms persist, other causes should be considered. This case report describes a jejunal carcinoid tumor with colonic extension that was diagnosed in a paraplegic patient with persistent constipation and diarrhea. A 39-year-old man sustained a T1 paraplegia with neurogenic bowel and bladder dysfunction from a gunshot wound. His bowels were initially managed adequately with digital disimpaction. Over the next 8 years, he had intermittent constipation that was managed with the addition of various suppositories. He then developed progressively worsening constipation, and other gastrointestinal (GI) symptoms. Although his symptoms initially resolved with medical management, the constipation worsened. Upper endoscopy revealed a submucosal bulge in the duodenal bulb. A month later, gallstones were found on renal ultrasound performed to evaluate recurrent urinary tract infections. He underwent cholecystectomy, but his GI symptoms persisted over the next several months. Repeat upper endoscopy subsequently revealed an ulcerated tumor at the duodenojejunal flexure. An upper-GI scan with small bowel follow through showed a proximal jejunal mass. The patient underwent laparotomy with resection of the mass. Final pathologic diagnosis was malignant carcinoid tumor. This case shows the importance of entertaining other clinical entities in patients with SCI when constipation and diarrhea persist despite adequate management.     

Ileus following radiotherapy: importance and therapeutic aspects of surgery for late radiation injuries of the intestine

Between 1971 and 1988 74 operations for intestinal complications following radiotherapy were performed on 67 patients at the Second Surgical Department, University of Vienna. The lesions were located in the small bowel (n = 41) and in the sigmoid colon/rectum (n = 33). 98.5% of the patients were females, the most frequent cause for irradiation being ovarian cancer. Bowel stenosis with resultant chronic or acute ileus was the most frequent indication for operation, occurring in 31 cases (76%) of the small bowel lesions and in 15 cases (46%) of the colon lesions. Percutaneous irradiation resulted in a significantly higher proportion of small bowel lesions (77%, p = 0.001), whilst endocavitary irradiation was followed in 67% of cases by colorectal lesions. Different application modality of irradiation also resulted in completely different symptoms for small and large bowel lesions. The operative mortality was 9.5%. Peritonitis following anastomotic leakage was the cause of death in 6 of 7 cases. In the treatment of small bowel ileus mortality following bowel resection (9%, one of 11 cases) was comparable to that of the bypass operation (6%, one of 18 cases). Both operation methods seem to be justified. Single-layer anastomosis resulted in zero mortality in 21 cases of ileus operated on by this technique, compared with 19% mortality in 16 cases treated by double-layer anastomosis and should be preferred for operations on the irradiated bowel.     

Role of colonoscopy in gallstone ileus:--a case report

This paper reviews the role of colonoscopy in large-bowel obstruction by a gallstone. We report the case of an elderly female with a cholecystocolonic fistula who had a large-bowel obstruction caused by a gallstone that migrated to the level of narrowing in the large bowel. After multiple attempts at removal of the stone with a snare and basket retriever, the patient was taken to the operating room and the stone was removed. Colonscopy in these circumstances can be diagnostic and possibly therapeutic.     

Identification of gallbladder mucin-bilirubin complex in human cholesterol gallstone matrix. Effects of reducing agents on in vitro dissolution of matrix and intact gallstones.

The goals of this study were to isolate and characterize the nonlipid matrix of human cholesterol gallstones. The lipid portion of gallstones was dissolved in ethanol/ether, leaving an insoluble, granular, brown-black matrix that constituted 12.5% of solitary large stones and 3.5% of multiple small stones. The matrix was partially solubilized by sonication and studied by exclusion gel chromatography and density gradient ultracentrifugation. On Sepharose 2B column chromatography, bile pigment eluted with glycoprotein in the void volume, suggesting the presence of a high molecular weight complex (Mr greater than 2 X 10(6)). The identity of mucin in this complex was confirmed by its typical buoyant density during ultracentrifugation. The major bile pigments in the matrix were identified as bilirubin (84%) and bilirubin monoglucuronide (15%) by thin-layer chromatography. Because of their ability to solubilize mucin-type glycoproteins, we tested the ability of the reducing agents 2-mercaptoethanol (2ME) and N-acetylcysteine (NAcCys) to solubilize gallstone matrix. Both reducing agents caused a two- to threefold enhancement of matrix dissolution after 4 d compared to aqueous buffer alone (P less than 0.01). Sepharose 2B chromatography revealed that 2ME released a high molecular weight mucin-bilirubin complex as well as unbound pigment from the insoluble matrix. We also tested the effect of reducing agents on dissolution of matched cholesterol gallstones by monooctanoin, a cholesterol solvent. Both 2ME and NAcCys significantly accelerated gallstone dissolution in monooctanoin. Matched human cholesterol stones (n = 10) incubated for 4 d in monooctanoin plus either 2ME or NAcCys (1 M final concentration) weighed approximately half as much (P less than 0.01 for each) as stones incubated in monooctanoin alone. This study describes, for the first time, the isolation of a bilirubin-mucin complex in the insoluble matrix of human cholesterol gallstones. The ability of reducing agents to dissolve the matrix and thereby accelerate gallstone dissolution by monooctanoin in vitro may be relevant to gallstone dissolution in humans.     

Duodenal obstruction by gallstones (Bouveret's syndrome): a review of the literature

Bouveret's syndrome, first described in 1896, is gastric obstruction by a gallstone following a cholecystoduodenal fistula. Endoscopy is the mainstay of diagnosis, but radiographic examination such as upper gastrointestinal contrast series and abdominal radiography can also contribute to the diagnosis. Diagnosis by computed tomography and ultrasonography has also been described. The syndrome can be diagnosed and treated endoscopically, with stone extraction or mechanical lithotripsy. Extracorporeal shockwave lithotripsy has also been used successfully. Surgery is required in over 90% of cases, with mortality rates ranging from 19% to 24%. One-stage and two-stage procedures have been described, including enterolithotomy, cholecystectomy, and fistula repair, no convincing data are available to show which of these two approaches provides a better outcome. Although the condition is rare, Bouveret's syndrome should be considered in elderly patients with a history of chronic cholecystitis who present with pain, vomiting or haematemesis.     

胆囊结石并发急性胰腺炎的超声诊断价值

目的探讨胆囊结石并发急性胰腺炎的超声诊断价值。方法采用超声检查37例胆囊结石并发急性胰腺炎患者,观察胆囊内结石大小与数量并进行比较,同时观察胰腺大小形态、实质回声及周围情况。结果胆囊结石中83.8%（31/37）为多发性结石,其中80.6%（25/31）为直径小于0.9cm的小结石。结论多发性且直径小的胆囊结石患者急性胰腺炎的发病率明显增高。超声检查胆囊结石可为临床提供急性胰腺炎的可能病因,并为胆囊结石患者选择性地施行胆囊切除术提供影像学诊断依据。     

Laparoscopic management of adhesive acute postoperative small bowel obstruction

Laparoscopic management of postoperative acute adhesive small bowel obstruction (SBO) may often have clinical advantages. This prospective study included patients with postoperative acute SBO in whom sufficient intestinal decompression was achieved using a nasoenteric ileus tube preoperatively, but pass disorder was not improved. This study describes our experience with the laparoscopic procedure for patients with adhesive acute SBO. The laparoscopic approach was undertaken in 24 of 51 patients admitted for acute postoperative SBO from July 1994 through June 2000; it was performed successfully in 20 patients (83%), and four cases were converted to open surgery (17%) because of strong adhesions. In four patients with gallstones and inguinal hernia, laparoscopic surgery (cholecystectomy, hernioplasty) was performed simultaneously. There was no mortality and low morbidity (4.1%). The group of patients treated laparoscopically had a shorter hospital stay than the conventional open group (12 versus 21 days; p < 0.05). At the median follow-up of 84 months, 21 of the 22 patients who had received laparoscopic procedure remained asymptomatic. Laparoscopic treatment was effective, involved a shorter hospital stay and has shown good long-term results for most patients with adhesive acute SBO.     

Chenodeoxycholic acid therapy for gallstones: effectiveness, toxicity and influence on bile acid metabolism.

Chenodeoxycholic acid (1 g daily) was administered to 10 patients with gallstones and three patients with biliary stricture and recurrent cholangitis. Four gallstone patients showed diminution or disappearance of stones including one patient whose stone was in the common bile duct. The patients with recurrent cholangitis showed marked improvement in symptoms during treatment. Serum bile acid levels were significantly elevated in 8 gallstone patients during treatment. Liver biopsy in eight gallstone patients during treatment revealed minor changes in five. Lithocholic acid and bile acid sulphates were found in only small amounts in the bile of patients during treatment. No significant trend in biliary lipid composition during treatment was observed. There was no overall trend in the group of patients whose stones disappeared or diminished. Changes in biliary bile acid composition and in bile acid pool sizes were variable following treatment and could not be correlated with the clinical results of treatment. A further trial of chenodeoxycholic acid is recommended in patients with stones in the biliary tree and recurrent cholangitis who are not amenable to surgical treatment.     

结直肠癌致肠梗阻的外科诊治体会

目的：探讨大肠癌致肠梗阻的诊断和手术方法。方法：回顾分析2002～2008年间65例结直肠癌致肠梗阻病例的外科治疗资料。结果：术后出现并发症9例,切口感染6例,腹腔感染2例,吻合口瘘1例。结论：结直肠癌致肠梗阻应争取Ⅰ期切除吻合。合理选择手术方式,做好术中结肠灌洗和围手术期治疗是手术成功关键。