Clinical image

Gallstone ileus with cholecystoduodenal fistula

Junji Machi, M.D., Ph.D., Alvin Ikeda, M.D., John Yarofalir, M.D., Toshiro Yahara, M.D.,Nobuyuki Miki, M.D.

University of Hawaii and Kuakini Medical Center, 405 N. Kuakini St., Suite 601, Honolulu, HI 96817, USA

An 88-year-old man came to the emergency room with a3-week duration of intermittent abdominal pain, followedby nausea and vomiting for 3 days. He did not have anyhistory of abdominal surgery or biliary diseases. He wasafebrile and physical examination showed moderate abdom-inal distension without tenderness. White blood cell countwas 10,900/mm3 with 45% bands. Liver function tests were

within normal limits. A computed tomography with contrastdemonstrated ascites in the upper abdomen, air and contrastin the contracted gallbladder (arrow in Fig. 1), and a pos-sible laminated gallstone at the terminal ileum (arrow inFig. 2).

Surgery is indicated for a patient with gallstone ileus toremove a stone from the intestinal tract. Performance ofconcomitant biliary procedures during the same operation isdetermined mainly by the condition of a patient, but also by

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The American Journal of Surgery 183 (2002) 56–57

0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved.PII: S0002-9610(01)00830-3

factors such as the extent of the inflammation around thebiliary tract, the condition and location of biliary enteric fistula(some fistulas close with fibrous remnant), and the presence orabsence of biliary obstruction due to bile duct stones. Intraop-erative cholangiogram can provide valuable information butmay be difficult to perform because cannulation for contrastinjection is not easy or possible. Intraoperative ultrasonogra-phy is helpful in this setting, because the ultrasound scanningcan be performed without any tissue dissection.

In this patient, laparotomy was performed with the use ofintraoperative ultrasonography. Near the terminal ileum,there was a palpable stone, confirmed by intraoperativeultrasonography (arrow in Fig. 3). The 3.5 � 2 cm stonewas removed through ileotomy. A marked inflammation

with adhesion was noted at the hepatoduodenal ligamentarea. Intraoperative ultrasonography showed a contractedgallbladder containing small stones and air. Cholecystoduo-denal fistula was identified and accurately localized by ul-trasonography, which demonstrated the dynamic movementof fluid and air between the gallbladder and duodenum inreal-time (arrows in Fig. 4). The bile duct was normal insize (6 to 7 mm) without stones or pneumobilia on ultra-sound examination. Because the patient was in a stablecondition, cholecystectomy was performed. The fistula wasdetected and excised. The duodenal opening was closed bysutures with an omental patch. Although the patient hadrenal failure and respiratory failure, he recovered from thesepostoperative complications and was discharged.

57J. Machi et al. / The American Journal of Surgery 183 (2002) 56–57