REVIEW ARTICLE Gallstone ileus: unusual cause of bowel ...

802copy IJMDC httpswwwijmdccom

International Journal of Medicine in Developing Countries

Gallstone ileus unusual cause of bowel obstruction Experience of an African center and literature reviewMohamed Bouzroud1 Aboulfeth el mehdi1 Essarghini Mohamed1 Ait Idir Badr1 Ait Ali Abdelmounaim1 Bounaime Ahmed1

ABSTRACT

Gallstone ileus (GI) is an uncommon cause of bowel obstruction that is associated with high rates of morbidity and mortality Management of GI remains controversial due to concerns about timing and prioritization of management of coexisting bowel obstruction and cholecystoenteric fistula This retrospective study reports five cases which were treated in the surgery department for GI in a hospital in Rabat and a literature review Of the five patients identified the average age was 62 years Length of obstruction prior to operation was 28 days Intraoperatively the size of the gallstones ranged from 25 to 38 cm in diameter Eighty percent patients underwent a simple enterolithotomy and only one had a laparoscopically assisted surgery Mortality in this series was 20 and the single patient death was attributed to comorbid conditions In this series of five patients GI affected the more elderly population (average age 62 years) and the diagnosis was established 2 to 3 days after the onset of symptoms Given the high rates of morbidity and mortality associated with the management of GI a simple enterolithotomy remains the best solution and one stage procedure should be reserved mainly for younger patients

Keywords Gallstone ileus biliary enteric fistula enterolithotomy one stage procedure laparoscopic assisted surgery

1 Introduction

Gallstone ileus (GI) is an unusual cause of bowel

obstruction Described for the first time by Bartholin in

1654 this entity affects mainly elderly people thus the

morbidity and mortality rates are not negligible [12]

Its management is still controversial between those who

prefer a simple enterolithotomy and those who require

a treatment for the biliary fistula The aim of this study

was to draw attention to this rare pathology its clinical

presentation and its treatment modalities through both

the presented experience and a literature review

2 Subjects and Methods

This is a report of a retrospective study of five patients

seen at the Military Hospital of Rabat and diagnosed

with GI from January 2008 to January 2018 as well

as a literature review (Table 1) Five different surgeons

managed the care of patients in this series GI is defined

as having a bowel obstruction secondary to a blockage in

the small bowel due to a gallstone A clinical observation

of small bowel adhesion up to the wall of the gallbladder

was also required for this to be classified as GI

3 Results

Among the five patients included in this study three

(60) were females with an average age of the studied

group at 62 years Only three cases reported a history of

biliary symptoms

All the patients presented signs of small bowel obstruction

without fever or jaundice The average time of diagnosis

was 24 days after the onset of symptoms Except for one

patient the computed tomography showed the classical

Correspondence to Mohamed BouzroudPresentpermanent address Service de chirurgie viscerale 1 hopital militaire drsquoinstruction mohamed V Rabat MoroccoEmail drbouzroudgmailcomFull list of author information is available at the end of the articleReceived 07 June 2019 | Accepted 17 July 2019

Mohamed Bouzroud et al 20193(10)802ndash805httpsdoiorg1024911IJMDC51-1559908102

REVIEW ARTICLE

Gallstone ileus an unusual cause of bowel obstruction

803

Riglerrsquos triad (small bowel obstruction pneumobilia and

ectopic stone) (Figures 1 and 2)

All the patients underwent surgery and only one

patient had a laparoscopic assisted operation A simple

enterolithotomy was the procedure of choice for 80 of

the cases A one-stage procedure was done for the youngest

patient in this series after the manual manipulation of the

gallstone through the narrow ileocecal valve into the

cecum where it could pass without an enterotomy A

cholecystectomy and a repair of the cholecystoduodenal

fistula were then performed (Figures 3ndash6)

Except for an elderly patient who died from cardiovascular

complications 2 days after surgery all the others left the

hospital on the third day with no long term complications

being reported in the average follow up of 5 years

4 Discussion

41 Diagnosis

GI is an uncommon cause of small bowel obstruction it

represents less than 5 of all mechanical obstructions

[34] This entity is due to chronic inflammation of the

gallbladder leading to a bilioenteric fistula Itrsquos frequently

located between the gallbladder and the duodenum (23ndash

965) but it can also concern the jejunum the colon or

the stomach [45] Stones with a diameter of less than 25

cm usually are expected to pass through the remaining

digestive tract while those over 25 cm are mainly blocked

in the terminal ileum and in the ileocecal valve due to

their relatively narrow lumen and potentially less active

peristalsis [36] Rarely the duodenal bulb becomes

the site of stone impaction and leads to a gastric outlet

obstruction [5]

This rare entity mainly affects the elderly population

with a female to male ratio estimated at (3 1) [457] Its

symptoms are mainly nonspecific like abdominal pain

Figure 1 CT scan showing stones in the gallbladder and pneumobilia

Figure 2 CT scan showing small bowel obstruction with an ectopic stone in the ileo cecal junction

Figure 3 Operative view of a gallstone ileus also showing the difference between dilated and decompressed bowel loops

Table 1 Patientrsquos age comorbidities surgical procedures and outcomes

Patients n (5)Age (median in years) 62 (44ndash74)

Gender Male Female

2 (40)3 (60)

Previous biliary symptoms 3

Average Time to diagnosis (in days) 28

Site of obstruction Terminal ileum Jejunum

4 (80)1

Type of fistula Cholecystoduodenal Not specified

41

Surgery type Open Laparoscopic Propulsion of stone into Colon and fistula repair Enterolithotomy

411

4

Surgical outcomes Length of stay (in days) Mortality

31


804

nausea vomiting abdominal distension and jaundice

A study found that 27 to 80 of patients may have a

past history of cholecystitis or other biliary symptoms

[5] Consequently the preoperative diagnosis is obtained

only in 50ndash60 of cases with an average time until

diagnosis ranging from 3 to 45 days [89]

Rigler [10] described a triad of radiological signs (small

bowel obstruction pneumobilia and ectopic stone) that

might lead to the diagnosis of GI CT imaging is much

more sensitive and GI is diagnosed at a frequency of

778 as compared to 148 with radiographs and only

111 with ultrasonography [11]

Despite modern imaging the diagnosis of GI is often

made only after operative abdominal exploration

42 Treatment

Topics in the management of GI that still remain

controversial include whether to concurrently excise

the cholecystoenteric fistula superiority of laparoscopic

or open surgery and the timing of reoperation to repair

the fistula Three strategies are possible a simple

enterolithotomy a one stage procedure (Enterolithotomy

with cholecystectomy and fistula closure) or a two-

stage procedure (Enterolithotomy followed by a delayed

cholecystectomy and a fistula repair 4 to 6 weeks later)

[51213]

As demonstrated through the largest published review

of GI during the last century Reisner and Cohen [9]

showed that enterolithotomy alone was safer with lower

mortality than other procedures A retrospective review

published in 2014 about 3268 cases of GI concludes

that independently of patients and hospital factors a

one-stage procedure is associated with higher mortality

length of hospital stays and consequently a higher overall

hospital charge [4] Thus a one-stage procedure with

concurrent fistula closure should be reserved for younger

patients with low comorbidities [414]

43 Recurrent GI

The literature estimates the risk of GI recurrence (GIR)

between 5 to 8 [15ndash18] It is the result of an untreated

biliary-enteric fistula with cholelithiasis however it can

also occur because of a non-obstructive biliary stone

(more proximal in the small intestine) which escaped

detection during the first surgery A systematic review

related to the recurrence of GI (from 1912 to 2015) reports

113 cases and concludes that 85 reoccurred within 6

months from the first intervention and 626 within 6

weeks Most of the patients (867) were treated initially

by simple enterolithotomy and only 19 had a single

stage procedure [18]

The GIR represents a difficult challenge for most

surgeons because they have to treat the emergency

obstruction and also if possible manage any causes

of recurrence Results from the previous study [18]

showed that mortality wise enterolithotomy was safer

(mortality estimated at 48) than single stage surgery

(224)

44 Laparoscopic approach

Laparoscopic treatment of GI is uncommon and

requires advanced surgical skills In the present series

only one patient (20) had a laparoscopically assisted

enterolithotomy while in the review published by Halabi

et al [4] 10 of cases were managed laparoscopically

Moberg et al demonstrated through a retrospective

study that laparoscopic enterolithotomy is feasible

and represents a better choice of treatment with lower

morbidity and lower complications than the open

approach

Figure 6 Extracted stone

Figure 4 Laparoscopic view of GI

Figure 5 Stone visualized through a longitudinal antimesenteric enterotomy


805

5 Conclusion

GI is an uncommon complication of cholelithiasis

which affects mainly the elderly population To decrease

morbidity and mortality rates a simple enterolithotomy

(laparoscopically assisted if possible) represents the

best choice A two-stage procedure with delayed fistula

repair is primarily required for young patients to prevent

recurrence

List of AbbreviationsGI Gallstone ileusGIR Gallstone ileus recurrence

Conflict of interestThe authors declare that there is no conflict of interest regarding the publication of this article

FundingNone

Consent for publicationNot applicable

Ethics approvalNot applicable

Author detailsMohamed Bouzroud1 Aboulfeth el mehdi1 Essarghini Mohamed1 Ait Idir Badr1 Ait Ali Abdelmounaim1 Bounaime Ahmed1

1 Surgery Department (I) Military Hospital Rabat Morocco

References

1 Martin F Intestinal obstruction due to gall-stones Ann Surg 191255(5)725ndash43 httpsdoiorg101097 00000658-191205000-00005

2 Deckoff SL Gallstone ileus A report of 12 cases Ann Surg 1955142(1)52ndash65 httpsdoiorg10109700000658-195507000-00007

3 Gupta M Goyal S Singal R Goyal R Goyal SL Mittal A Gallstone ileus and jejunal perforation along with gangrenous bowel in a young patient a case report N Am J Med Sci 2010442ndash43 httpsdoiorg104297najms20102442

4 Halabi WJ Kang CY Ketana N Lafaro KJ Nguyen VQ Stamos MJ et al Surgery for gallstone ileus Ann Surg 2014259(2)329ndash35 httpsdoiorg101097SLA0b013e31827eefed

5 Nuntildeo-Guzmaacuten CM Gallstone ileus clinical presentation diagnostic and treatment approach World J Gastrointest Surg 20168(1)65 httpsdoiorg104240wjgsv8i165

6 Hussain Z Ahmed MS Alexander DJ Miller GV Chintapatla S Recurrent recurrent gallstone ileus Ann R Coll Surg Engl 201092(5)e4ndash6 httpsdoiorg101308147870810X12659688851753

7 Mallipeddi MK Pappas TN Shapiro ML Scarborough JE Gallstone ileus revisiting surgical outcomes using national surgical quality improvement program data J Surg Res 2013184(1)84ndash8 httpsdoiorg101016jjss201305027

8 Muthukumarasamy G Venkata SP Shaikh IA Somani BK Ravindran R Gallstone ileus surgical strategies and clinical outcome J Dig Dis 20089(3)156ndash61 httpsdoiorg101111j1751-2980200800338x

9 Reisner RM Cohen JR Gallstone ileus a review of 1001 reported cases Am Surg 199460441ndash6

10 Rigler LG Borman CN Noble JF Gallstone obstruction J Am Med Assoc 1941117(21)1753 httpsdoiorg101001 jama194102820470001001

11 Lassandro F Gagliardi N Scuderi M Pinto A Gatta G Mazzeo R Gallstone ileus analysis of radiological findings in 27 patients Eur J Radiol 200450(1)23ndash9 httpsdoiorg101016jejrad200311011

12 Abou-Saif A Complications of gallstone disease Mirizzi syndrome cholecystocholedochal fistula and gallstone ileus Am J Gastroenterol 200297(2)249ndash54 httpsdoiorg101111j1572-0241200205451x

13 Dai X-Z Gallstone ileus case report and literature review World J Gastroenterol 201319(33)5586 httpsdoiorg103748wjgv19i335586

14 Clavien P-A Richon J Burgan S Rohner A Gallstone ileus Br J Surg 199077(7)737ndash42 httpsdoiorg101002bjs1800770707

15 Pronio A Piroli S Caporilli D Ciamberlano B Coluzzi M Castellucci G et al Recurrent gallstone ileus case report and literature review G Chir 20133435ndash7

16 Buetow GW Glaubitz JP Crampton RS Recurrent gallstone ileus Surgery 196354716ndash24


18 Mir SA Management and outcome of recurrent gallstone ileus a systematic review World J Gastrointest Surg 20157(8)152 httpsdoiorg104240wjgsv7i8152


803

Riglerrsquos triad (small bowel obstruction pneumobilia and

ectopic stone) (Figures 1 and 2)

All the patients underwent surgery and only one

patient had a laparoscopic assisted operation A simple

enterolithotomy was the procedure of choice for 80 of

the cases A one-stage procedure was done for the youngest

patient in this series after the manual manipulation of the

gallstone through the narrow ileocecal valve into the

cecum where it could pass without an enterotomy A

cholecystectomy and a repair of the cholecystoduodenal

fistula were then performed (Figures 3ndash6)

Except for an elderly patient who died from cardiovascular

complications 2 days after surgery all the others left the

hospital on the third day with no long term complications

being reported in the average follow up of 5 years

4 Discussion

41 Diagnosis

GI is an uncommon cause of small bowel obstruction it

represents less than 5 of all mechanical obstructions

[34] This entity is due to chronic inflammation of the

gallbladder leading to a bilioenteric fistula Itrsquos frequently

located between the gallbladder and the duodenum (23ndash

965) but it can also concern the jejunum the colon or

the stomach [45] Stones with a diameter of less than 25

cm usually are expected to pass through the remaining

digestive tract while those over 25 cm are mainly blocked

in the terminal ileum and in the ileocecal valve due to

their relatively narrow lumen and potentially less active

peristalsis [36] Rarely the duodenal bulb becomes

the site of stone impaction and leads to a gastric outlet

obstruction [5]

This rare entity mainly affects the elderly population

with a female to male ratio estimated at (3 1) [457] Its

symptoms are mainly nonspecific like abdominal pain

Figure 1 CT scan showing stones in the gallbladder and pneumobilia

Figure 2 CT scan showing small bowel obstruction with an ectopic stone in the ileo cecal junction

Figure 3 Operative view of a gallstone ileus also showing the difference between dilated and decompressed bowel loops

Table 1 Patientrsquos age comorbidities surgical procedures and outcomes

Patients n (5)Age (median in years) 62 (44ndash74)

Gender Male Female

2 (40)3 (60)

Previous biliary symptoms 3

Average Time to diagnosis (in days) 28

Site of obstruction Terminal ileum Jejunum

4 (80)1

Type of fistula Cholecystoduodenal Not specified

41

Surgery type Open Laparoscopic Propulsion of stone into Colon and fistula repair Enterolithotomy

411

4

Surgical outcomes Length of stay (in days) Mortality

31


804















42 Treatment










[51213]












43 Recurrent GI



















(224)











approach





805

5 Conclusion







recurrence



FundingNone





References




















804















42 Treatment










[51213]












43 Recurrent GI



















(224)











approach





805

5 Conclusion







recurrence



FundingNone





References




















805

5 Conclusion







recurrence



FundingNone





References



















REVIEW ARTICLE Gallstone ileus: unusual cause of bowel ...

Documents

Transcript of REVIEW ARTICLE Gallstone ileus: unusual cause of bowel ...