Gallstone Ileus Research Articles

Gallstone Ileus in the Absence of Gallbladder, Rare Etiology of Bowel Obstruction: A Case Report and Literature Review

Background: Gallstone ileus post-cholecystectomy is extremely rare surgical emergency causing mechanical bowel obstruction. This condition is usually misdiagnosed due to its non-specific clinical features. Radiological investigations are essential to evaluate and diagnose gallstone ileus cases. Case Presentation: A 92-year-old female patient, cholecystomized, presented to our hospital with a one-week history of an acute confusional state, generalized abdominal pain, and vomiting. The physical examination showed a disoriented patient with a distended abdomen and generalized tenderness, especially in the epigastric area. Hyperactive bowel sounds were audible. Laboratory investigations were non-specific. A plain abdominal X-ray was insignificant. The abdominal ultrasound showed marked abdominal gaseous distention. Then, an abdominal CT scan was performed, revealing an impression of gallstone ileus causing small bowel obstruction with no evidence of fistula formation. So, surgical intervention was decided, and an 8-gram gallstone was exteriorized through an enterolithotomy. The postoperative period was uneventful. Discussion: Gallstone ileus is an unusual entity that often affects elderly females. The clinical features of gallstone ileus include abdominal pain, abdominal distension, nausea, and vomiting. Diagnosis of gallstone ileus relies on imaging and physical examination. Abdominal CT with contrast provides a definitive diagnostic tool. The surgical options to manage the gallstone ileus can be either one or two-staged enterolithotomy. Conclusion: Due to the rare etiologic origin of the gallstone ileus in post-cholecystectomy cases, we report the case of a 92-year-old female with an acute confusional state and generalized abdominal pain, found to be caused by detected gallstone ileus, lacking evidence of fistula formation.

Management of complex acute biliary disease for the general surgeon: A narrative review

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

A255 CHOLECYSTO-COLONIC FISTULA AND GASTRIC OUTLET OBSTRUCTION DUE TO EXTRINSIC COMPRESSION: A RARE BOUVERET-LIKE SYNDROME

Abstract Background Bouveret syndrome is a rare form of gastric outlet obstruction due to gallstone ileus. It is caused by passage of a large stone from the gallbladder into the duodenum via a bilio-duodenal fistula causing gastric outlet obstruction. It was first described by Leon Bouveret in 1896 and occurs most commonly in elderly patients with a higher incidence in women. In classic Bouveret syndrome, the stone itself becomes impacted in the intestinal lumen. A case series of 128 cases found only 2 cases where the endoscopic finding was of extrinsic compression. Purpose To present a rare case of Cholecysto-colonic fistula and gastric outlet obstruction due to extrinsic compression as a rare Bouveret-like syndrome. Method Chart review was conducted including clinical notes, laboratory, radiographic, and endoscopy reports. A relevant literature review was conducted. Result(s) A 76-year-old female with recent hospitalization for weight loss, anemia and cognitive decline presented to hospital with sudden onset vomiting without abdominal pain. She was admitted to general surgery. CT scan of the abdomen and pelvis were done and described a subhepatic inflammatory mass with inflammation of the proximal duodenum causing a partial gastric outlet obstruction as well as a fistula between with hepatobiliary system and a loop of ascending colon with associated pneumobilia. The etiology of the fistula was unclear but thought to be due to infection vs malignancy vs stone disease and the patient was put on antibiotic therapy. Due to inability to tolerate oral intake, she was put on parenteral nutrition. The Gastroenterology (GI) service was then consulted for consideration of gastroscopy and possible stent placement for obstruction. The GI service requested an MRI for further characterization. This revealed a 20mm impacted gallstone in the fistula tract with 3 other similarly sized stones passed into the colon, as well as evidence of a partial outlet obstruction due to the inflammatory mass in the porta hepatis. Gastroscopy was pursued to identify any intraluminal compression, which revealed duodenal edema in the first segment of the duodenum without any intraluminal pathology. Given that the compression was not intraluminal, a stent was not offered. Surgical options would be extensive surgery including cholecystectomy, duodenal wedge resection and partial colonic resection. Given her comorbidities, plan was made for conservative management instead. After 2 weeks of admission and conservative management, her outlet obstruction resolved and she was able to tolerate oral intake again. Image Conclusion(s) Impacted gallstones causing chronic cholecystitis can result in fistula formation with the colon and due to the size of the stones in the tract and resultant inflammation, extrinsic compression of the duodenum may occur presenting as clinical gastric outlet obstruction. In this event, conservative management can be an effective strategy of management as a safe alternative to extensive surgical resection and bypass. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Comparison between surgical techniques in gallstone ileus and outcomes

Comparison between surgical techniques in gallstone ileus and outcomes

Images in Surgery: Rigler’s Triad—the Classical Diagnostic CT Scan Finding in Gallstone Ileus

Images in Surgery: Rigler’s Triad—the Classical Diagnostic CT Scan Finding in Gallstone Ileus

Gallstone ileus of the sigmoid colon: case report.

Here the authors report the case of a 74-year-old woman who was admitted to Compiegne Hospital in France for a gallstone ileus with the sigmoid colon as the impaction site, which is an even more rare cause of intestinal obstruction. The enterobiliary fistula was between the colon and the gallbladder.The gallstone was removed surgically with a colotomy, without treating the fistula, and after a failed endoscopic attempt to extract the stone. The follow-up was without complications, and a colposcopy showed spontaneous closure of the fistula after 6 weeks. The surgical closure of an enterobiliary fistula is an option that should be considered, but it can lead to higher morbidity. That is why the authors opted out of it, especially considering that spontaneous closure of the fistulae can happen, as it did in our case.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

Different Approaches to the Management of Cholecystoenteric Fistula

A cholecystoenteric fistula is an anomalous communicating tract between the gallbladder and any segment of the gastrointestinal tract. It is a rare complication of gallstone disease and typically affects elderly patients with multiple medical comorbidities. These fistulae can present in a variety of ways, and the diagnosis is often made only after extensive workup. Despite notable advances in imaging techniques in the last half-century, a considerable number of cases are still discovered incidentally during open or laparoscopic surgery. We present a series of 3 cases, each with different etiologies and presentations, but all of whom were found to have a cholecystoenteric fistula. Each case was managed differently, highlighting the diversity of this intriguing condition.

Gallstone Obstruction In Jejunum: A Rare Case

Gallstone ileus refers to mechanical obstruction of the small intestine due to impaction of one or more gallstones. It occurs as a complication of cholelithiasis, more in elderly females [1]. CECT is the best diagnostic tool and the definitive treatment of gallstone ileus is surgical removal. The prevalence of cholelithiasis among American Indians may reach upto 70% and is much lower in Asians[6]. However most cases of cholelithiasis are asymptomatic and are found as an incidental finding and it is reported that on an average 1-2.3% of patients experience complications[8]. Gallstone ileus occurs due to inflammation and erosion of any part of the biliary tree leading to enterobiliary fistula through which the stone passes. Patients usually present with non-specific symptoms and acute cholecystitis is present in 10–30% cases[9]. Diagnosis clinically poses a challenge due to vague presentation with nonspecific symptoms but a radiological diagnosis on CECT and MRCP can be made. Enterolithotomy is a definitive procedure with or without cholecystectomy, fistula closure. The ongoing inflammation may complicate cholecystectomy and fistula repair. Considering that most patients are older with multiple comorbidities with added physiological stress, multiple procedures are not done in the same setting. Though laparoscopic/ laparoscopy assisted surgeries have reported better efficiency and lesser complications, less availability of equipment and surgeon’s skills and training are often a limiting factor. As there are variabilities in the surgical approaches the patient factors and surgeon factors must be kept well in mind and then to proceed with the surgery of choice. With all these at the back of the mind, higher success rates with lesser hospital stay, perioperative events and mortalities are achievable.

A review of the first 100 robotic cholecystectomies with a new cart-based surgical robot at a tertiary care centre.

Robotic cholecystectomy appears to be a natural evolution of the well-established gold standard procedure for gallstones, namely laparoscopic cholecystectomy. Akin to the early days of laparoscopy, robotic surgery is associated with a learning curve. We present our experiences in adapting to robotic surgery after the first 100 robotic cholecystectomies at a minimal access surgery tertiary care hospital. The first consecutive 100 robotic cholecystectomies performed by a single surgeon on the Versius robotic surgical system (CMR Surgical, UK) were included in the study. Patients unwilling to give consent and complex pathologies such as gangrene, perforation and cholecystoenteric fistulas were excluded from the study. Operative time, robotic setup time, incidence and indication for conversion to manual (laparoscopic) procedure were recorded while subjective assessment of interruptions due to machine alarms and errors was made. All data were compared between the first 50 and last 50 procedures. Our data revealed a gradual reduction in operative time from 28.53 min for the first 50 procedures to 22.06 min for the last 50 procedures. An improvement in draping and setup times was also noted, reducing from 7.74 to 5.14 min and 7.96 to 5.32 min, respectively. There were no conversions during the last 50 procedures, though the first 50 procedures resulted in 3 conversions to a laparoscopic procedure. In addition, we also noted a subjective reduction in the incidence of machine errors and alarms as we became more versed with the robotic system. Our single-centre experience indicates that newer modular robotic systems present a rapid and natural progression for experienced surgeons looking to venture into robotic surgery. The well-established advantages of robotic surgery in the form of enhanced ergonomics, three-dimensional vision and improved dexterity are validated as indispensable aids in a surgeon's armamentarium. Our initial experience reveals that robotic surgery for more common surgical procedures such as cholecystectomies will be rapidly accepted, safe and effective. There is a need to innovate and expand the range of instrumentation and energy devices available.

A Case of Early Recurrent Gallstone Ileus. What to do about the Residual Gallbladder Stone?

A Case of Early Recurrent Gallstone Ileus. What to do about the Residual Gallbladder Stone?

A Particular Case of Gallstoneileus: Diagnostic Imaging and Treatment

Gallstone ileus is a rare condition that affects females and older adults. It is caused by a connection between the bowel and the gallbladder that allows the migration of gallstones into the bowel leading to mechanical obstruction. In this case report, we present a case of an 88-year-old female who came to our observation for abdominal pain and vomiting. With the help of a series of radiological investigations, we arrived at the diagnosis of a rare disease called “Gallstone ileus”.

Gallstone Ileus—Lessons from a Missed Diagnosis

AbstractGallstone ileus is an uncommon presentation in patients with acute abdomen. Its diagnosis and treatment are often delayed due to its nonspecific clinical presentation. Presence of gallstone in ileum can be difficult to detect on computed tomography (CT) as mostly they are lucent. We report the case of a 66-year-old man with a 1-day history of vomiting and abdominal bloating. Initial CT could not identify the obstructing gall stone. On the follow-up CT, there was a distal shift of obstruction site in the intestine raising suspicion of a gallstone. We discuss the imaging findings on CT and the clues to diagnosing gallstone ileus.

Gallstone Ileus: A Rare Surgical Emergency

Background : Gallstone ileus is a rare complication of cholelithiasis and is an uncommon cause of intestinal obstruction accounting for 1%–4% of mechanical bowel obstructions. This usually results from luminal impaction of one or more gallstone.
 Case Presentation : A 86-year-old male presented with the history of bilious vomiting for 15 days and abdominal distension for 8 days and diagnosed as a case of intestinal obstruction due to gall stone ileus. He was treated surgically by laparotomy followed by enterotomy and removal of gall stone were performed from the proximal ileum.
 Conclusion : Early diagnosis and treatment are important otherwise adverse effect of mechanical bowel obstruction leads to bad prognosis.
 Chatt Maa Shi Hosp Med Coll J; Vol.21 (2); July 2022; Page 57-59

OGBN P09 Sharing the experience of the use of Spyglass DS - guided electrohydraulic lithotripsy (SG-EHL) in the treatment of large gallstone causing Bouveret syndrome

Abstract Background Less than 1% of intestinal obstruction is accounted for by gallstone ileus. Gallstone ileus is a mechanical intestinal obstruction resulting from gallstone impaction within the gastrointestinal tract. Under 3% of gallstone ileus are caused by gallstone impaction in the duodenum or pylorus, which can give rise to a gastric outlet obstruction, described by Bouveret in 1896. Surgical intervention involves the removal of the stone by either a gastrotomy or duodenotomy, which is associated with significant morbidity. Advancement in endoscopic techniques, allows for more complex procedures, therefore, reducing the need for a surgical intervention and its accompanying morbidity. This abstract presents a rare case of a large gallstone (22mm×34mm) partially impacted in the duodenum of a 92-year-old female, which was treated with the Spyglass DS-guided electrohydraulic lithotripsy (DS-EHL). Methods A 92-year-old female with a previous history of gallstone ileus was treated by surgical intervention. The patient continued to complain of abdominal discomfort and occasional vomiting. A CT scan revealed a fistulous communication to the duodenal bulb, containing a large gall stone (22mm x34 mm). After consultation with the patient, an initial assessment with the use of standard endoscopy under general anaesthesia confirmed the visualisation of a portion of the gallstone in the duodenum, hanging through a well-established cholecysto-dudenal fistula. SPyglass DS - guided lithotripsy (SG-EHL) was used in the treatment of the large gallstone. Results Electrohydraulic lithotripsy (EHL) was attempted through the standard gastroscope, but we were unable to secure a safe position to target the stone. Therefore, a side view duodenoscope was used along with the SpyGlass DS to obtain good visualisation and stable access to target the stone with the EHL. The Spyglass guided electrohydraulic lithotripsy (SG-EHL) was used to fragment the stone. Despite consuming four EHL wires and using higher settings, we only managed to break the shell of the stone, reducing its size by approximately 3mm all around. The laser was not available at the time; therefore, the procedure was concluded. The patient had an uneventful recovery and was discharged home. No further symptoms were recorded by patient on follow up 5 months later. Conclusions Endoscopic management of an impacted gallstone causing gastric outlet obstruction is found to be safe and carries less morbidity than the traditional surgical approach. Therefore, it should be considered for being the procedure of choice to treat patients with Bouveret syndrome. Laser lithotripsy should be available on standby for cases that involve stones that are harder to break.

OGBN P13 Management of Bouveret Syndrome: an endoscopic approach

Abstract Background Bouveret syndrome is rare complication of gallstones with 600 reported cases since 1950. The syndrome occurs when adhesions develop between the gallbladder to surrounding hollow viscera leading to fistula formation. Large gallstones migrate into the enteric system and become impacted in the stomach or duodenum causing gastric outflow obstruction. Bouveret syndrome accounts for 1–4% of gallstone ileus cases. It is more common in co-morbid women in their 7th and 8th decades. Most common symptoms are vomiting and abdominal pain. Upper gastrointestinal bleeding is reported in 15% of cases. CT scan has the highest sensitivity at 79–93% to make the diagnosis. Of note 15–25% of gallstones are isoattenuating. Riglers triad is a diagnostic marker and consists of aerobilia, a gastric outflow obstruction or dilated bowel and the presence of a calculus outside of the biliary tree. The diagnosis was associated with mortality rates as high as 30% but with modern advances mortality has decreased to approximately 12%. Treatment options are surgical or endoscopic retrieval. Endoscopic management carries less risk especially in the frail elderly patient. This approach has low success rates. We present a case of successful endoscopic management of Bouveret syndrome and discuss surgical and endoscopic management strategies. Methods A frail 83 year old female attended ED with epigastric pain, vomiting and signs of sepsis. She had a recent diagnosis of severe cholecystitis that was managed conservatively. On examination she had tenderness in the right upper quadrant. Bloods revealed an AKI, a CRP 189 and normal liver function tests. Axial imaging showed aerobilia with a CBD dilated at 14mm and there was a 3.5cm calculus impacted in the duodenum with a cholecysto-duodenal fistula. Her medical history included diabetes mellitus, atrial fibrillation, hypertension, primary hyperparathyroidism, reflux and cauda equina (operated). On OGD there was a large stone which had eroded into the first part of the duodenum. A combination of mechanical lithotripsy and the Kudo snare were used to fragment the stone. 2 large fragments were retrieved using a bag to avoid gallstone ileus. Results The patient had an uneventful but slow recovery. She re-established oral intake on the second post-operative day. She was discharged 2 weeks later without complication. Conclusions The success of endoscopic management is reported as low as 10%. Endoscopic intervention is attempted in 61% of cases. Success is more likely with stones <4cm and if the site of impaction is the stomach or D1/D2. Surgical management is associated with a morbidity rate of 26% but was successful in 78%. Laparoscopic surgery is possible but less successful in stones >5cm. Endoscopic techniques have evolved and should be considered for extraction of stones in the first instance. If not feasible surgery can be considered. The literature shows that success is more likely when various endoscopic techniques are utilized including mechanical lithotripsy, nets and baskets, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy, laser lithotripsy and duodenal stenting. There is a risk of distal migration of stone fragments causing gallstone ileus in the more distal small bowel. Bouveret syndrome can be resolved with endoscopy in expert hands.

OGBN P10 Laparoscopic management of cholecystoduodenal and cholecystocolic fistulas: technical considerations and postoperative outcomes

Abstract Background Cholecystoduodenal and cholecystocolic fistulas are rare complications of gallstone disease. They are usually diagnosed intraoperatively, posing significant surgical challenges. The aim of this study is to review the incidence, presentations, difficulty grading, technical aspects and their management outcomes on a unit adopting a policy of index admission cholecystectomy for all comers with biliary emergencies. Methods A prospectively maintained database of all laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) performed over a 30 years period between 1992 to 2022 by a single surgeon was reviewed. All biliary emergencies who were fit for anaesthesia were managed with an intention to treat during the index admission. Procedures involving cholecystoenteric fistulas or suspicious attachments were analysed. The clinical presentation, imaging, operative findings and outcomes were analysed. All suspicious cholecystoenteric attachments were dissected and encircled, confirming a fistula was achieved by access through the gallbladder lumen and, in most cases, obtaining either a duodenography or a colonography before disconnecting and repairing the fistula. Although staplers were not used in this series the technique may enhance the security of closure and prevent occasional complications resulting from minor intraoperative or postoperative leakage. Results 59/6000 (1%) patients had cholecystoduodenal and cholecystocolic fistulas (46) or dense fibrous attachments (13) where careful dissection revealed no obvious fistula. 67.8% were female and the median age was 68 years. 33 (56%) were emergency admissions, including 20 jaundiced and 8 with acute cholecystitis. Of 26 admitted electively 6 had previous acute cholecystitis. 32 (54.2%) had risk factors for CBD stones. ERCP was done in 5 and of cross sectional imaging in 15 patients only one suspected a cholecystocolic fistula. LCs were classified difficulty grade IV (28) or V (31). 29 (49.15) required LCBDE: 11 (18.6%) by trancystic exploration and 18 (30.5%) via choledochotomy. 12 patients had Mirizzi abnormalities and 3 had gallbladder, biliary or duodenal cancers. Subhepatic drains were used in 54 (91.5%). Median operative time was 145 minutes (range 35–375). One patient was converted to open due to significant adhesions. Perioperative complications occurred in 32%: 4 t-tube complications, 3 bile leaks, 3 chest infections, 3 intraabdominal collections requring relaparoscopy and 6 miscellaneous. The rate of complications specific to the presence of such fistulas was only 12%. There were 2 deaths with respiratory infection. Median hospital stay was 10 days (range 1–160). Conclusions When dense fibrosis and adhestions to bowel loops are encountered, a high index of suspicion is particularly important as 44% present electively with chronic symptoms. When an attachment is suspected to be a fistula it should be isolated, approached through the gallbladder lumen to confirm a fistula. Ligation is carried out before division and appropriately securing the fistula using seromuscular sutures. The laparoscopic approach to managing cholecystoduodenal and cholecystocolic fistulas is not currently widely practiced as the operative findings results in a low threshold for open conversion. However, laparoscopic resolution is feasible with appropriate training and experience thus avoiding conversion to open surgery which may help reduce the relatively high morbidity associated with such encounters.

Single stage totally laparoscopic management of Barnard’s syndrome: the first such case report with review of literature

Gall stone ileus is an uncommon however important complication of cholelithiasis. This condition is seen commonly in elderly females with comorbidities. It results from the passage of stone into the small bowel from the gall bladder through a cholecysto-duodenal fistula. Presenting symptoms include typical features of small bowel obstruction. Diagnosis can be made radiologically. Surgical management is the mainstay of treatment. The procedure can be done either in a single stage, where the stone retrieval is done through enterotomy followed by cholecystectomy and fistula repair; or in two stages, which comprise of enterolithotomy alone in stage 1 followed by interval cholecystectomy and fistula repair in stage 2. Laparoscopic single stage management enables definitive surgical therapy of the condition during a single hospital stay and under a single session of anaesthesia.

Gallstone ileus: a friquently missed diagnosis, case report and review of literatures

Gallstone ileus: a friquently missed diagnosis, case report and review of literatures

Cholecystocolonic fistula, a rare complication of cholelithiasis: case presentation

Introduction: Cholecystocolonic fistula is usually a rare and late complication of gallstones and is the second most common cholecystoenteric fistula. Objective: To present the case of a cholecystocolonic fistula, a rare complication of cholelithiasis. Presentation of the case: A 50-year-old female patient who comes to our institution for recurrent abdominal pain. Discussion: Patients with FCC usually have a variable clinical presentation and are more often asymptomatic. When symptomatic, patients generally present with diarrhea, abdominal pain, jaundice, fever, nausea, vomiting, steatorrhea, and weight loss. The combination of pneumobilia, chronic diarrhea, and vitamin K malabsorption has been proposed as a pathognomonic triad for cholecystocolonic fistula. Conclusions: Cholecystocolonic fistula is a rare entity, radiologists should be aware of it and should be carefully informed if it occurs together with other hepatobiliary anomalies. The clinical triad pneumobilia, chronic diarrhea, and prolonged prothrombin time is seen in less than one third. Almost three quarters of the cases are asymptomatic and are diagnosed intraoperatively. Where cholecystectomy and repair of the colon wall is the most used treatment method.