Gallstone Ileus Research Articles

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond.

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

A Rare Presentation of Intestinal Obstruction: Gall Stone Ileus

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract.1 It is an unusual complication of cholelithiasis, occurring in fewer than 0.5 percent of patients.2 Typically as a result of the formation of cholecysto-duodenal fistula, surgical removal of the gallstone is the mainstay of treatment in order to relieve the intestinal obstruction. Objective: To know about this rare diagnosis so that one can keep it as a differential diagnosis for intestinal obstruction and thus manage accourdingly. Keywords: Intestinal obstruction, Gallstone ileus, Bouveret’s syndrome, Cholecystoduodenal fistula, Bilio-enteric fistula.

Gallstone ileus, controversies on current surgical management

Among the causes of bowel obstruction, the gallstone ileus represents a rare etiology in the general population, however, the incidence of cases increases in older adults. To make its diagnosis, a high clinical suspicion and extension studies are required. It is considered a surgical emergency, although the ideal approach continues to be debated today. We present the case of a 78-year-old patient with clinical and imaging findings compatible with gallstone ileus, the diagnostic and therapeutic approach, as well as a wide review of the literature about current surgical option.

EGS P27 Twice Recurrent Gallstone Ileus Requiring 3 Laparotomies – A Case Report

Abstract Background Gallstone ileus is a well-known and not an uncommon complication of gall stone disease, with standard management being an enterotomy and extraction of the obstructing gallstone with management of the gallbladder and the billio-enteric fistula being deferred to an interval procedure if indicated. Recurrent gallstone ileus are not unheard of, but are quite rare and are the reason cited by the proponents of a single stage procedure. While a single stage procedure is possible - involving an enterotomy as well as a challenging cholecystectomy and the management and closure of a duodenal fistula – more commonly than not it is not performed. Methods Twice recurrent gallstone ileus is extremely rare and on performing a literature review only 1 published case report has been identified. Here we present the case of an 87-year-old Caucasian female, presenting with 3 incidences of gall stone ileus in a 30 day period requiring 3 laparotomies. Initial presentation to our institution was in November 2022 with a CT proven localised Gallbladder perforation. The first presentation with gallstone ileus was on 21/03/2023 with symptoms of bowel obstruction and CT proven obstructing 23mm gallstone 8 cm from the ileocaecal valve as well as pneumobillia and two other stones in the gallbladder. Results The index laparotomy was performed and no transition point was found, and bowel run-through from DJ to ICV revealed no intraluminal gall stones and the caecum was full of fluid. The gallstone had passed into the colon spontaneously and no enterotomy was performed. Two subsequent laparotomies were required due to CT proven incidence of recurrent Gallstone ileus on 30/03/2023 and 20/4/2023, were enterotomies were performed and the obstructing stones extracted each time. An informed decision not to tackle the gallbladder and the duodenal fistula was taken by a consensus of 3 consultant surgeons due to the frailty of our patient. Conclusions Our patient made a meaningful recovery after developing an entero-cutaneous fistula that resolved with conservative management and was discharged home on 15/05/2023. While our patient's frailty and previous gallbladder perforation made the decision not proceed with a cholecystectomy and repair of the duodenal fistula a straightforward one, the incidence of twice recurrent gallstone ileus in the span of a month raises questions as to whether other techniques should be considered in a more fit patient such as a single stage operation or a Cholecystolithotomy.

EGS P23 A rare case of gallstone ileus post Roux-en-Y Gastric Bypass: Stone migration from large duodenal diverticulum

Abstract Background Small bowel obstruction following Roux-en-Y gastric bypass is common and is mainly attributed to adhesions or internal herniation. Intraluminal formation of stones, usually in areas of stasis due to the anatomical changes post-RYGB, and migration to the distal ileum to cause acute bowel obstruction is rare. Impacted stones at the duodenal diverticulum can trigger diverticular inflammation, back pressure to the common bile duct and pancreas resulting in abdominal pain, nausea and vomiting, intermittent derangement of liver enzymes and episodes of cholangitis and pancreatitis. The impaction at the distal ileum is an emergency requiring prompt diagnosis and intervention to prevent complications. Methods This is a case report of a 56-year-old female who presented at East Surrey Hospital in February 2023 with recurrent upper abdominal pain, nausea and vomiting. She previously underwent an open cholecystectomy for cholelithiasis and cholecystoduodenal fistula (2003) and a Roux-en-Y gastric bypass (2018). Her symptoms were initially thought to be secondary to inflammation and periduodenal abscess managed with antibiotics, but as time and scans (CT, MRCP, water-soluble contrast, gastroscopy) progressed without resolution of her symptoms it became evident that she had developed mechanical bowel obstruction. We described her case and the diagnostic challenges leading to the final surgical management. Results To investigate the patient’s symptoms, her intermittently raised inflammatory markers, deranged liver enzymes and amylase a series of radiological examinations was rperformed. Initial CT scan showed an inflamed large duodenal (D3) diverticulum and fluid filled proximal duodenum. Subsequent MRCP demonstrated dilated common bile duct and intrahepatic ducts without any ductal stone. Repeat CT scan two weeks later, confirmed small bowel obstruction due to a heterogenous bolus at the ileocecal valve with resolution of the duodenal inflammation and dilatation. The patient underwent a laparoscopic extraction of a stone impacted at the ileocecal valve causing small bowel obstruction and recovered well. Conclusions Even though small bowel obstruction due to stone aggregation is uncommon post-RYGB, a high index of suspicion for the diagnosis and a low threshold for early laparoscopic intervention can prevent further serious complications. Reporting these cases in literature offers a guidance for the workup and management of these unusual scenarios amongst surgical teams and improves patients’ outcomes.

Delayed presentation of gallstone ileus due to spilled gallstones: A case report

Introduction: Gallstone ileus is a rare cause of intestinal obstruction and very few cases have been reported of spilled gallstones during a cholecystectomy resulting in a delayed presentation of gallstone ileus. Although complications from unretrieved gallstones are rare, there is a variety of post-operative complications described in the literature. Most complications occur within the first few months but can occur up to 10 years after the procedure. If complications arise, they may lead to significant morbidity and management may result in an invasive intervention, including a laparotomy. Case Report: An 83-year-old female underwent laparoscopic cholecystectomy for acute cholecystitis, during which several large gallstones spilled and an attempt at retrieval was made. Six years later, she presented to the emergency department with a small bowel obstruction due to gallstone ileus caused by an unretrieved spilled gallstone. She underwent laparotomy, and the gallstone was retrieved from the terminal ileum. Conclusion: Gallstone ileus can occur because of unretrieved spilled gallstones from a cholecystectomy. Although complications from unretrieved gallstones are rare, this case report highlights the importance of considering this as a differential diagnosis when patients present with symptoms consistent with intestinal obstruction after a cholecystectomy. It is important to attempt to retrieve spilled gallstones during cholecystectomy, but if this is not feasible, this should be documented, and patients should be informed of the potential risks of unretrieved stones although rare.

Obstructive quandary: A comprehensive case report of gallstone ileus

Gallstone ileus (GI), an infrequent but complex complication of cholelithiasis, poses a multifaceted challenge in the field of general surgery. We present a case report of a 99-year-old male with GI, characterized by mechanical obstruction within the small bowel due to gallstone impaction, and offer a review of the literature on this subject. GI emerges as a late-stage complication of gallstone disease, primarily manifesting in elderly individuals, with a higher incidence among women. The condition is driven by the migration of gallstones through fistulas, most commonly forming connections with the small bowel. Diagnosis is intricate due to nonspecific clinical symptoms, often requiring imaging modalities like abdominal CT scans. Treatment necessitates surgical intervention, addressing both intestinal obstruction and cholecystoenteric fistula management. The approach, whether one-stage or sequential, is guided by individual patient characteristics.

An important cause of mechanical bowel obstruction in older patients: gallstone ileus.

An important cause of mechanical bowel obstruction in older patients: gallstone ileus.

Cholecystoduodenal Fistula with Gallstone Ileus Presenting as Upper Gastrointestinal Bleeding

Cholecystoduodenal Fistula with Gallstone Ileus Presenting as Upper Gastrointestinal Bleeding

S4069 Saved by the Bowel: Gallstone Ileus in an Unusual Patient Population

S4069 Saved by the Bowel: Gallstone Ileus in an Unusual Patient Population

S3388 Successful Endoscopic Management of Gallstone Ileus Using Electrohydraulic Lithotripsy

S3388 Successful Endoscopic Management of Gallstone Ileus Using Electrohydraulic Lithotripsy

S2187 A Case of Gallstone Ileus Presenting Post Percutaneous Cholecystostomy

S2187 A Case of Gallstone Ileus Presenting Post Percutaneous Cholecystostomy

Íleo biliar: análisis de 21 casos

Background: Gallstone ileus is a rare complication of cholelithiasis and mainly affects elder women. It is caused by gallstone migration through a cholecystoenteric fistula producing bowel obstruction, with the need for surgical treatment. Objective: The aim of this work was to describe the preoperative, intraoperative and postoperative variables of a case series of gallstone ileus and the incidence of recurrent gallstone ileus. Material and methods: We conducted an observational and retrospective study of patients undergoing surgery due to acute bowel obstruction caused by gallstone ileus between January 2009 and December 2021. The variables analyzed were imaging tests, comorbidities, surgical approach, type of surgery, morbidity and mortality and recurrent ileus. Results: Of 667 patients admitted with bowel obstruction, 21 had gallstone ileus (3.1%). The diagnosis was made by computed tomography scan in 80% of the cases. The surgical approach was laparotomy in 20 cases and 1 patient undergoing laparoscopy required conversion. Enterotomy with enterorrhaphy was the most common procedure used in 18 cases. The obstruction was treated by immediate surgery, while the biliary fistula was deferred in most cases because the risk of immediate treatment was very high. Morbidity was 38% and recurrence of gallstone ileus 4.7%. No deaths were reported. Conclusion: Gallstone ileus was a rare condition that was correctly diagnosed and timely treated with surgery, with a low incidence of recurrent gallstone ileus.

Comparing outcomes of operative management of intestinal obstruction due to gallstone ileus using NSQIP database

Comparing outcomes of operative management of intestinal obstruction due to gallstone ileus using NSQIP database

539 Antegrade Manipulation and Retrieval per Rectum: A Novel Management Approach for Gallstone Coleus

Abstract Gallstone ileus is a rare complication of gallstone disease, while gallstone coleus is rarer still. Like gallstone ileus, it affects mainly elderly female patients. It is associated with high mortality and morbidity, as frailty is a significant issue in the patient demographic. In this case report, we discuss a 94-year-old, who presented with large bowel obstruction secondary to a large gallstone in the mid-sigmoid colon. Neither conservative management nor retrieval via flexible sigmoidoscopy were successful. Due to worsening bowel obstruction, the decision to operate was made. Due to frailty, a pre-operative decision was made that she would not be for bowel resection or enterotomy. A hybrid flexible sigmoidoscopic/ laparotomy assisted removal was successful: a Pfannenstiel incision was made, the stone was milked distally, and eventually retrieved with flexible sigmoidoscopy via the anus. We propose that in frail patients, a combined approach using laparotomy and flexible sigmoidoscopy may be considered as a method of gallstone removal. This avoids the significant risks associated with enterotomy or bowel resection.

Gallstone Ileus: A Stone In The Way

Gallstone ileus, a rare complication of cholelithiasis, is caused by an impaction of gallstones within the gastrointestinal tract leading to mechanical intestinal obstruction. Here in, we describe a case of gallstone ileus in a 62-year-old woman successfully treated with enterolithotomy. The patient was discharged home after an uneventful post-operative period. Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal obstruction, with often delayed presentation and non-specific symptoms. The preferred approach is enterolithotomy. Elective cholecystectomy after the acute episode is controversial.

Bouveret s syndrome in a young stable patient Clinical case report and summary of evidence

Bouveret’s syndrome is an infrequent cause of bowel obstruction, and the less frequent presentation form of gallstone ileus with high mortality. Only 315 cases have been reported until 2016. Given the scarce number of cases, there is no consensus on the appropriate management. We present the case of a middle-aged Mexican woman referred to a high specialty surgical center with imaging evidence of duodenal calculus and bilioenteric fistula. A 10 x 5 cm gallstone impacted in the duodenum was removed via an open anterior gastrotomy. She had good postoperative course. Each case should be treated based on patient’s health status, location and size of the gallstones as well as experience and availability of minimally invasive techniques.

Gallstone Ileus; the Radiographic Findings in an Elderly Patient: A Case Report

Since the beginning of the COVID-19 pandemic in December 2019, Ivermectin has been proposed as an alternative for prophylaxis and treatment of COVID-19 infection despite the lack of evidence and clinical trials recommending its use. In this study, we report the case of a 52-year old Filipino male with newly diagnosed diabetes mellitus who developed a subacute history of fever, cough and generalized weakness, causing him to self-medicate with supratherapeutic doses of Ivermectin and thereafter subsequently developed decrease in sensorium, restlessness and complex visual hallucinations. Significant laboratory examinations showed hyperglycemia, mild hyponatremia, positive SARS-CoV2 reverse transcriptase polymerase chain reaction test and bilateral pneumonia on chest radiograph. He was subsequently started on antibiotics, high flow nasal cannula and given two doses of activated charcoal. During the first 24 hours of hospital admission, there was significant improvement in the patient’s sensorium with resolution of restlessness and visual hallucinations. During the rest of the hospitalization, his respiratory symptoms had improved and he was subsequently discharged. Clinical outcome in our patient after administration of activated charcoal and completion of antibiotics showed an overall improvement in symptoms and without any neurologic sequelae.

118 Bouveret Syndrome: A Rare Case of a Huge Gallstone causing Gastric Outlet Obstruction

Abstract Introduction Bouveret syndrome is a rare case of gallstone ileus resulting from an acquired fistula connecting the gallbladder and either the stomach or duodenum and cause intestinal obstruction. Case Summary A 85-year-old female presented with epigastric pain non-bilious vomiting and absolute constipation for five days. She patient was tachycardiac and was dehydrated. Abdomen was distended. Bowel sounds were absent. Digital rectal examination was unremarkable. Abdominal radiography did not demonstrate pathological air-fluid levels, rather revealed a dilated gastric shadow, suggestive of gastric outlet obstruction. The patient was immediately managed with nasogastric intubation and intravenous hydration. Subsequent esophagogastroduodenoscopy (EGD) was planned to rule out carcinoma owing to the age of the patient. EGD revealed a dilated stomach and a hard, golf-ball-sized gallstone in the third part of the duodenum. The scope could not be passed beyond the impacted stone, nor could it be extracted endoscopically. CT tomography revealed a distended stomach with a large gallstone obstructing duodenum and pneumobilia . One-stage surgical procedure was planned. Intraoperative findings included a thick-walled gallbladder with surrounding inflammation and a fistulous tract connecting the gallbladder with the duodenum. A gallstone measuring 3.7cm in diameter was retrieved from the third part of duodenum via enterotomy. The fistulous tract was closed, and cholecystectomy was performed and drain was placed. Patient was discharged on 4th postop day. Conclusion Bouveret syndrome is an infrequent presentation causing gastric outlet obstruction and is often overlooked owing to its rarity. High index of suspicion is necessary when patients present with bowel obstruction and a history of gallstones to prevent morbidity and mortality from Bouveret syndrome.