Rare Complication Of Gallstone Disease Research Articles

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.

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.

S1841 The Curious Case of CA 19-9 in Mirizzi Syndrome

Introduction: Mirizzi Syndrome (MS) is a rare complication of gallstone disease, caused by an obstructing stone in the cystic duct or the gallbladder neck, leading to obstruction of the common hepatic duct. This case discusses the utility of EUS in improving diagnostic yield of MS and the importance of cancer screening in these patients. Case Description/Methods: A 44-year-old male with a history of gastritis presented with right upper quadrant (RUQ) abdominal pain, jaundice, and scleral icterus for one week. On exam, the patient was afebrile with mild RUQ abdominal tenderness. Labs showed a total bilirubin of 5.4 mg/dL, AST of 66 U/L, ALT of 228 U/L, and a total alkaline phosphatase of 159 U/L. Ultrasound demonstrated intra- and extrahepatic biliary dilation with suggestion of a shadowing stone within the common bile duct (CBD). The gallbladder wall was thickened with trace pericholecystic fluid. MRCP showed a 15 mm calculus presumed to be in the CBD, with a 16 mm CBD dilation. ERCP showed a filling defect in the midportion of the CBD, and a CBD stent was placed. Due to these findings, a CA 19-9 antigen was drawn, measuring 3038 U/mL. EUS was then performed, which visualized a cystic duct stone partially extending into the CBD– a finding consistent with MS. An enlarged lymph node was visualized in the porta hepatis region. FNA of the lymph node as well as CBD brushings from the ERCP were both negative for malignant cells. The patient was discharged and underwent a cholecystectomy two weeks later. Surgical findings were consistent with MS and a 20 mm stone was removed with the gallbladder. The intraoperative frozen section of the gallbladder was negative for malignant cells. (Figure) Discussion: Initial evaluation for MS should include an ultrasound or CT scan, followed by MRCP. The pooled sensitivity of MRCP for detecting CBD stones is around 87%. While MRCP is often used to diagnose MS, the anatomy may not be well visualized due to the proximity of the cystic duct to the CBD. EUS has a pooled sensitivity of 97% in detecting a CBD stone and can better visualize the biliary tract anatomy, aiding in diagnosis. Diagnosis of MS prior to surgery can be helpful in avoiding biliary tract injuries. MS evaluation should also include screening for malignancy, as MS has an association with gallbladder cancer. While elevated CA 19-9 levels are concerning for malignancy, they can also be seen in chronic benign biliary obstruction. It is important to obtain a CA 19-9 level when suspecting MS, both before and after stone removal.Figure 1.: A. MRI: A T2-weighted image showing a 15 mm filling defect (white arrow) within the cystic duct, partially extending into the common bile duct, consistent with an obstructing stone. Intrahepatic and extrahepatic biliary dilation is also seen. B. Endoscopic ultrasound: An ovoid, hyperechoic structure, measuring 11 mm x 15 mm, with shadowing suggestive of a gallstone at the level of the cystic duct and compression of the common bile duct. C. Endoscopic ultrasound: An irregularly contracted gallbladder (black arrow) with adjacent dilated common bile duct. D. Endoscopic ultrasound: Fine needle aspiration of an enlarged lymph node with well defined margins in the porta hepatis region, measuring 20 mm x 15 mm in maximal cross-sectional diameter. Color Doppler imaging was utilized prior to needle puncture to confirm a lack of significant vascular structures within the needle path.

S2835 Gastro-Cholecysto-Colonic Fistula Following Endoscopic Ultrasound-Guided Gallbladder Drainage for Stump Cholecystitis: A Case Report

Introduction: Cholecystocolonic fistulas (CCF) usually occur as a complication of gallstones but cases due to malignancy, peptic ulcers, and Crohn’s disease have been reported. We present a case of a gastro-cholecysto-colonic fistula after endoscopic ultrasound guided-gallbladder drainage (EUS-GBD) for stump cholecystitis. Case Description/Methods: A 50 year old male presented with abdominal pain. CT scan noted acute cholecystitis. He underwent laparoscopic converted to open subtotal cholecystectomy due to significant inflammation around the gallbladder. He represented 3 weeks later for abdominal pain. CT showed stump cholecystitis. Gastroenterology was consulted for EUS-GBD given his poor surgical candidacy. Diagnostic EUS revealed choledocholithiasis. Endoscopic retrograde cholangiography (ERC) with cholangioscopy, electrohydraulic lithotripsy, and stone removal was completed. Transgastric EUS-GBD with a 10 x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS) was then performed followed by double pigtail stent (DPT) placement within the LAMS. At a follow up visit, abdominal pain resolved but he developed debilitating diarrhea and was started on cholestyramine. Upper endoscopy 4 weeks after EUS-GBD revealed a gastro-cholecysto-colonic fistula with the proximal end of the DPT in the colon. Cholecystoscopy confirmed absence of gallstones so the LAMS and DPT were removed. Clips were used to close the cholecystogastric tract. Oral contrasted CT with delayed images showed tethering of the gallbladder to the hepatic flexure but no extravasation of contrast into the gallbladder from either the stomach or colon. Given this, clinical observation was pursued. Six weeks later, CT noted similar tethering without contrast leak. On colonoscopy, an area of inflamed mucosa at the hepatic flexure was seen without a patent fistula tract. Biopsies showed chronic colitis. Diarrhea subsequently resolved. (Figure) Discussion: CCFs are a rare complication of gallstone disease. If untreated, biliary sepsis can occur. Surgery is the standard treatment but endoscopic transpapillary gallbladder drainage with a DPT can promote fistula healing in non-surgical patients. We present a case of a gastro-cholecysto-colonic fistula in a poor surgical candidate after EUS-GBD for stump cholecystitis. This was managed with closure of the cholecystogastric tract. CCF closure occurred spontaneously. In cases of persistent CCF, transpapillary gallbladder drainage should be considered.Figure 1.: A. Double pigtail stent migrated into transverse colon with gastro-cholecysto-colonic fistula as viewed from the gallbladder lumen. B. CT scan showing tethering of hepatic flexure to remnant gallbladder (red arrow) without contrast extravasation into the gallbladder from the stomach or colon. C. Closed cholecystocolonic fistula (black arrow) viewed from the hepatic flexure.

S3384 Choledocystoduodenal Fistula Effectively Treated With a High-Dose Proton Pump Inhibitor: A Case Report

Introduction: Choledocystoduodenal fistulas are a rare complication of biliary or peptic ulcer disease. Approximately 91%-94% of spontaneous internal biliary fistulas are caused by stones in the biliary tract. The second most common cause is peptic ulcer. We present a case of a patient found to have a choledocystoduodenal fistula caused by peptic ulcer disease successfully treated with high-dose PPI. Case Description/Methods: A 73-year-old female with a history of duodenitis and gastritis presented for chronic intermittent abdominal pain. Physical exam was positive for epigastric tenderness. Labs were normal. Imaging revealed a large stool burden, mildly distended gallbladder without gallstones and a normal biliary tree. She was started on a once-daily PPI and a bowel regimen. EGD was performed and demonstrated a large necrotic duodenal lesion with copious purulent drainage (Figure A). Gastric biopsy was negative for H. pylori. The patient was readmitted for persistent abdominal pain, weight loss and loss of appetite. On physical exam, she had epigastric tenderness. She was afebrile and lab work was normal. CT abdomen and pelvis demonstrated small bowel thickening involving the duodenal bulb and first portion of the duodenum and air within the gallbladder with mild pericholecystic inflammatory changes. An EGD performed thereafter revealed the same duodenal bulb ulcer with a likely fistula (Figure B); injection of contrast through the tract under fluoroscopy confirmed a fistula to the gallbladder (Figure C). The patient was discharged on high-dose twice daily PPI, a short course of amoxicillin and clavulanic acid. Her symptoms resolved within 8 weeks. A surveillance EGD performed to assess healing demonstrated a healed scar at the site of the prior ulcer and fistula (Figure D). Discussion: Cholecystoenteric fistulas are a rare complication of gallstone disease and peptic ulcer disease, with an autopsy reported incidence rate of 0.1%-0.5%. Historically, surgical treatment is the most common treatment method for cholecystoenteric fistulas. Our case suggests that a high proton pump inhibitor dose for 8-12 weeks may be sufficient for the fistula to heal. By implementing medical management for this condition, it may be possible to avoid the morbidity and mortality associated with laparoscopic or open fistula repair.Figure 1.: A. Initial EGD showing large necrotic duodenal lesion with copious purulent drainage B. Second EGD demonstrating duodenal bulb ulcer C. Fluoroscopy with contrast injection demonstrating fistula tract communication with gallbladder D. Follow-up EGD after treatment with high dose PPI demonstrating healed choledocystoduodenal fistula with a small residual duodenal ulcer.

An Unusual Cause of Obstructive Jaundice

Question: A 45-year-old man presented with painless obstructive jaundice for 1 month. His past medical history was unremarkable. Significant laboratory results included total bilirubin of 73.4 μmol/L (normal 5.1-20 μmol/L), direct bilirubin of 46.5 μmol/L (normal <6.1 μmol/L), alanine transaminase of 168.3 U/L (normal 9-50 U/L), alkaline phosphatase of 438 U/L (normal 50-135 U/L) and gamma-glutamyl transferase of 1321.6 U/L (normal 10-60 U/L). Abdominal ultrasonography showed a gallstone in the common hepatic duct with intrahepatic ductal dilation, and the gallbladder was atrophic. Contrast-enhanced computed tomographic (CT) scan in a dual-energy mode showed luminal distension of gallbladder neck (Figure A, white arrow), with hepatic hilar stenosis (Figure A, blue arrow) and bilateral intrahepatic ductal dilation. Coronal virtual monoenergetic image reconstruction at 40 keV clearly showed an intraluminal lesion with hypodensity in gallbladder neck (Figure B, red arrow). The spectral Hounsfield unit curve showed the decreased attenuation values of the lesion as the energy level decreased (Figure C). What is the most likely diagnosis? Look on page 197 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Dual-energy CT suggested that the lesion was a cholesterol gallstone. Magnetic resonance cholangiopancreatography (MRCP) was then performed and confirmed a stone (Figure D, white arrow) in the gallbladder neck, with external compression of the common hepatic duct and dilation of the intrahepatic biliary duct, highly suggestive of Mirizzi syndrome (MS). In addition, a long cystic duct running parallel to the common bile duct with low insertion was found. Subsequent cholecystectomy confirmed a 1.7-cm cholesterol gallstone in the neck of the gallbladder causing hepatic hilar stricture, which was consistent with MS. The patient had an unremarkable recovery. MS, as a rare complication of gallstone disease, refers to impaction of a gallstone in the gallbladder neck or cystic duct causing obstruction of the extrahepatic bile duct.1Abou-Saif A. Al-Kawas F. Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus.Am J Gastroenterol. 2002; 97: 249-254Crossref PubMed Google Scholar MS can be tricky and may mimic cholangiocarcinoma, especially when gallstones are radiolucent on conventional CT.2Chen Y. Chang C. Liu K. Mirizzi syndrome due to a large radiolucent gallstone.Am J Gastroenterol. 2016; 111: 599Crossref PubMed Scopus (2) Google Scholar With the ability to differentiate materials on the basis of their differential attenuation at 2 different energy levels, dual-energy CT can help to identify the composition of internal body constituents, such as gallstones. Previous studies have reported that dual-energy CT can increase the conspicuity of isoattenuating gallstones.3Soesbe T.C. Lewis M.A. Xi Y. et al.A technique to identify isoattenuating gallstones with dual-layer spectral CT: an ex vivo phantom study.Radiology. 2019; 292: 400-406Crossref PubMed Scopus (15) Google Scholar In this case, dual-energy CT was first used to diagnose MS, clearly showing the gallstone in the gallbladder neck as the cause of the hepatic hilar obstruction, and to provide a diagnostic clue to confirm MS. This technique can potentially reduce the need for further imaging, such as MRCP, leading to a reduction in imaging cost and time to diagnosis for selected patients.

Surgical Management of Cholecystoenteric Fistula in Patients With and Without Gallstone Ileus: An Experience of 29 Cases.

BackgroundCholecystoenteric fistula (CEF) is an uncommon complication of cholelithiasis. Here, we report our experience on diagnostic methods and surgical management of CEF patients with and without gallstone ileus (GI).MethodsThis is a retrospective cases series over an 11-year period (2011–2022). Data analyzed included preoperative characteristics, ultrasound, imaging features, operation findings and postoperative course.ResultsA total of 29 patients diagnosed with CEF were enrolled, 51.7% (15/29) of whom were female, with a median age of 66 years (range: 35–96 years). With regards to subtype distribution, seventeen patients had cholecystoduodenal fistula (CDF), six had cholecystoconlonic fistula (CCF), three exhibited cholecystogastric fistula (CGF), one CDF combination with CCF and two CDF combination with type I Mirizzi syndrome. Twelve patients presented with gallstone ileus, and received one stage procedure or simple Enterolithotomy. The median operation time and blood loss of 157 min (range: 65–360 min) and 40 ml (range: 10–450 ml), respectively. Surgical complications, evidenced by fistula recurrence, were recorded in three patients (3/22; 13.6%), while four (4/29; 13.8%) and one patient (1/29; 3.4%) presented with wound infection and residual stone in common bile duct, respectively. No deaths were reported in our study.ConclusionCEF is a rare complication of gallstone disease that is occasionally found during operation. To date, no consensus has been reached regarding efficacious treatment therapies for CEF patients. For a CEF patient with GI, one stage procedure should be selected prudently, while simple Enterolithotomy would be a mainstream choice for relieving bowel obstruction.

A206 GALLSTONE IMPACTION IN THE DESCENDING COLON WITH SUCCESSFUL ENDOSCOPIC REMOVAL

BackgroundGallstone impaction in the colon is a rare complication of cholelithiasis, typically because of gallstones migrating into the colon via a cholecystocolonic fistula. Gastrointestinal obstruction from gallstones only develops in 0.3–0.5% of patients with cholelithiasis and accounts for 0.095% of all mechanical bowel obstruction. Successful treatment has been described with endoscopic and surgical techniques.AimsThis report aims to present a case of colonic obstruction from gallstone that was successfully treated endoscopically.MethodsWe conducted a retrospective chart review on one patient including assessing the history of presenting illness along with biochemical, radiographic, and endoscopic results. We then conducted a narrative literature review on this subject matter.ResultsAn 85-year-old male with known cholelithiasis complicated by prior cholecystitis presented with a 2-day history of generalized abdominal pain. Computed tomography (CT) showed fistulisation between the gallbladder and hepatic flexure. Follow-up CT with rectal contrast showed lack of contrast beyond an impacted gallstone in the descending colon (Figure 1A, 1B). The patient was deemed a poor surgical candidate thus endoscopic gallstone extraction was attempted. With a pediatric colonoscope, the 41mm x 51mm gallstone was visualized 70cm from anal verge (1C). The stone was too large to be extracted en-block with snare or basket. Attempts to cut the stone at its surface with a polypectomy snare and other tools were unsuccessful because of the roundness and smoothness of the stone. Although we could chip away at the surface, we were unable to break the seal of the stone against the colon mucosa. We found the most effective method was tunneling through the stone’s centre using a closed rat-tooth forceps, then angling the tip of the scope and pulling the scope back to break off fragments from within. A polypectomy snare was used to further breakup larger fragments to prevent repeat impaction (1D). There was underlying diverticular disease and mild ischemic changes to the mucosa but no stricture. The patient did well post-procedure and was able to tolerate oral intake, pass flatus, and pass bowel movements. He was discharged 3 days later.A recent systematic review found a total of 38 cases of gallstone obstruction of the colon. Majority of patients (73.6%) ultimately required surgical intervention. Overall mortality is 13.1%.ConclusionsGallstone impaction in the colon is uncommon with successful endoscopic treatment seldomly described. This report describes a rare complication of gallstone disease that was successfully treated with widely available endoscopic tools. Funding AgenciesNone

A Case of Gallstone Ileus after Cholecystectomy and Bilioenteric Bypass

Introduction: Gallstone ileus accounts for only 1-4% of all mechanical bowel obstruction cases. It is a rare complication of gallstone disease, and gallstone ileus occurring after cholecystectomy and bilioenteric bypass is even more rare.

P-BN30 Retroperitoneal biloma: a case report of spontaneous retroperitoneal bike leak and collection

Abstract Background Retroperitoneal biloma is a rare complication of gallstone disease. Only a handful of cases have been reported in the literature with various mechanisms postulated. Here, we report a case of spontaneous retroperitoneal biloma arising from gallbladder perforation. Methods An 87-year-old female patient presented with right upper quadrant pain in the context of known gallstone disease. Inflammatory markers and liver function tests were deranged. Cross sectional imaging found acute cholecystitis and a gallbadder neck perforation with an impacted 2cm proximal common bile duct (CBD) stone. A cholecystostomy was placed and she improved clinically. However, inflammatory markers remained high, and a subsequent computed tomography (CT) found a large collection in the retroperitoneum. Results The retroperitoneal collection measured 14cm x 7cm, and there had been evidence on prior CT scans of retroperitoneal inflammation. It was urgently drained under ultrasound guidance and found to contain bilious content. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) was unable to retrieve the CBD stone, but left stents either side of the stone. The patient clinically and biochemically improved. She was discharged and had an elective ERCP, which successfully retrieved the stone, with a plan for urgent elective laparoscopic cholecystectomy. Conclusions Here, we report an interesting case of retroperitoneal biloma successfully managed with ultrasound-guided drainage. Perforation of the distal CBD can result in retroperitoneal bile leak, but the proximal CBD stone in this case would have likely prevented passage of bile. A more likely cause is adhesion of the gallbladder neck to the posterior parietal peritoneum due to chronic inflammation, with subsequent perforation and release of bile into the retroperitoneum. This has previously been described in the literature. Regardless of mechanism, knowledge of the potential for this rare complication is important for anticipating and appropriately managing complications of gallbladder perforation.

EP.TU.581Cholecysto-colonic fistula – A rare complication of gallstone

Abstract We present a 90year old male patient presenting to the emergency department with complaints of PR bleed for a month with no associated abdominal pain. He described that the blood was mixed with stools and dark in colour. He has a significant past medical history with multiple comorbidities. The patient is known to have gallstones and had ERCP with sphincterotomy in 2017 as a definitive treatment, as he wasn’t a fit candidate for surgical intervention. On clinical examination, his abdomen was soft and non-tender and per rectal examination showed stools mixed with the blood but no active bleeding or fresh blood. His haemoglobin was 72 g/L, inflammatory markers were significantly elevated with deranged liver enzymes and normal bilirubin. The medical team were involved in the management of this patient because of pneumonia and extensive medical issues. A gastroscopy was performed as there was a suspicion of UGI bleed, which was normal. Given a deranged liver function and there was a suspicion of biliary sepsis patient had MRCP and Computed tomography of the abdomen which confirmed that there is haematoma in the gallbladder with gas in the biliary tree, with possible cholecysto-colonic fistula, with a large gall stone (2.7cm lamellated structure within rectum) in the rectum. As the patient was not a surgical candidate decision was made to manage him conservatively with antibiotics under medical care. The cholecysto-colonic fistula is a rare complication of gallstone disease, and very few cases have been reported in the literature.

Acute duodenal obstruction is a rare complication of gallstone disease

Acute duodenal obstruction is a rare complication of gallstone disease

Синдром Бувере (клінічний випадок)

Gallstone disease is one of the most common surgical nosologies, which tends to increase steadily. More than 2.5 million cholecystectomy surgeries are performed annually in the world: in European countries – from 45 to 80 thousand, in the United States – more than 700 thousand choledocholithiasis with the development of mechanical jaundice. Diagnosis of these complications in most cases is not difficult, and the provision of surgical care is standardized. Bouvet’s syndrome (syn. Acute biliary ileus, Gallstone ileus) is a very rare complication of gallstone disease and is caused by the development of inflammatory degenerative-dystrophic changes between the gallbladder and the duodenal wall, leading to the formation of fistulas through which -intestinal tract with the development of obstruction. However, it should be noted that only in 7–10% of cases, the formed fistula can cause the migration of stones and the development of intestinal obstruction. By 2008, only about 300 cases of the syndrome had been described in the world literature. Patients with a long history of stone disease, frequent episodes of exacerbation of cholelithiasis, female gender, old age are the main risk factors for Bouvere syndrome. Compared to other types of mechanical obstruction, the frequency of biliary ileus is only 1–4% and can reach 24% in people over 70 years. The complexity of the diagnosis is due to the nonspecificity of the initial manifestations, comorbidity of patients, late treatment. Postoperative mortality in acute calculous cholecystitis ranges from 0.28% to 3.01% (on average in Ukraine 0.94–0.81%), and in Bouvere syndrome can reach 24%. The main direct causes of death are bleeding, perforation, acute pancreatitis, severe dyselectrolyte disorders. The possibility of widespread use of computed tomography and magnetic resonance imaging greatly simplifies the diagnostic search. However, unfortunately, preoperative diagnosis of the syndrome is achieved only in a quarter of patients. Minimally invasive methods, given the growth of scientific publications and personal experience, can be successfully used to correct this pathology as a final method. A literature review of the etiology, pathogenesis, clinical manifestations, prevalence, methods of diagnosis and treatment of Bouvet syndrome is presented. Clinical case (short description). Presented own clinical observation of Bouvere syndrome in a patient hospitalized in the surgical department of the KNP «Regional Clinical Hospital named after O.F. Gerbachevsky» with the phenomena of duodenal immobility and long history of stone-bearing. Consecutive use of endoscopic and instrumental imaging methods allowed accurate diagnosis, and the use of laparoscopic access made it possible to perform minimally invasive correction of pathology in this patient. Conclusions. Gallstone disease is one of the most common surgical pathologies. Bouvere syndrome is a rare complication of the latter. Clinical symptoms are less specific, so the use of additional instrumental examinations allows accurate preoperative diagnosis. Due to the low efficiency of endoscopic methods of correction surgery is the main tool. The increase in scientific publications on the use of laparoscopic and video-assisting techniques makes it possible to argue about the relatively high efficiency of the latter in the correction of this pathology. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests. Key words: Gallstone disease, acute intestinal obstruction, Bouveret syndrome.

S1285 Gallstone Ileus: How Common Is the Uncommon? A Nationwide Perspective With Overview of Hospitalization Trends, Cost of Care, and Outcomes

INTRODUCTION: Gallstone ileus (GSI) is a rare complication of gallstone disease estimated to account for 1%–4% of all bowel obstructions. It is the result of gallstone impaction in the small bowel through a biliary-enteric fistula. Limited epidemiological data exists on the number of hospitalizations, demographic variations, cost of care, comorbidity measures, and outcomes for GSI. METHODS: We analyzed the National Inpatient Sample (NIS) database for all hospitalizations with GSI (ICD-9 code 560.31) as primary or secondary diagnosis during the period from 2001-2011. NIS is the largest all-payer inpatient care database in the United States, containing data on more than 7 million hospital stays. Its large sample size is ideal for developing national and regional estimates. Statistical significance of variation were determined using Cochran-Armitage trend test. RESULTS: Between 2001 and 2011, number of hospitalizations for GSI increased from 1048 to 1255 (P < 0.0001, Figure 1A). GSI was found to be more common in women (P = 0.12) and Caucasians (P = 0.03). Although age group 65–79 remained the most commonly affected, age group 50-64 showed the greatest rise from 17.8% to 25.8% (P < 0.0001, Figure 1B). South remained the most commonly affected region (P = 0.22) throughout the study period. There was a significant rise in the West from 20.6% to 25.0% (P = 0.002) with a concurrent decrease in the Northeast from 24.2% to 20.3% (P = 0.04). A proportional decrease in the number of hospitalizations was seen at both, urban non-teaching (45.6% to 41.6%, P = 0.29, Figure 1C) and rural hospitals (19.9% to 9.9%, < 0.0001, Figure 1C), while the number increased at urban teaching hospitals (34.5% to 46.7%, P < 0.0001, Figure 1C). There was an overall increase in the cost of care from $17,285 to $23,739 (P < 0.0001, Figure 1D) whereas the mean length of stay ranged from 9.5 to 11.1 days (P = 0.28). Overall mortality ranged from 4.3% to 8.6% (P = 0.005). Some of the most commonly associated comorbid conditions with GSI were hypertension, fluid and electrolyte disorders, diabetes mellitus, anemia, and chronic pulmonary disease (Figure 2). CONCLUSION: A significant rise in the number of hospitalizations with GSI was found with interesting demographic variations and association with comorbidities. Although there was no significant change in their length of stay, there was a significant rise in the cost of care during the study period, perhaps due to increased use of newer, more advanced, diagnostic and treatment modalities.Figure 1Figure 2

SMALL INTESTINAL OBSTRUCTION AS A RARE COMPLICATION OF GALLSTONE DISEASE

Small intestinal obstruction is a very rare complication of gallstone disease. It occurs when large stones are found in the gallbladder for a long time, which penetrate into the lumen of the duodenum through the cholecysto-duodenal fistula. Obstruction is more often observed in the terminal part of the ileum. The clinic is atypical and has a two-phase character. At the beginning of the disease, the clinic resembles acute cholecystitis, and then the clinical picture of acute intestinal obstruction develops. With the viability of the small intestine, the enterolithotomy is the optimal operation.

Surgical management of Mirizzi syndrome during the pandemic in a COVID 19 referral center: Report of a case from a developing country

&gt;Mirizzi syndrome (MS) is a rare complication of gallstone disease. Surgical management may be complex, depending on the type of Mirizzi, and may range from simple cholecystectomy to a hepaticojejunostomy. A 39-year-old female diagnosed previously to have gallstones was admitted in the Philippine General Hospital (PGH), a tertiary COVID 19 referral center presenting with obstructive jaundice, right upper quadrant pain and fever. Hepatobiliary ultrasonography demonstrated a markedly distended gallbladder with a stone at the Hartmann's pouch. A diagnosis of Mirizzi syndrome with cholangitis was made. The patient was managed with broad spectrum antibiotics and scheduled for surgery. No further imaging or endoscopy was requested due to the limitations brought about by the pandemic. Upon a negative COVID 19 polymerase chain reaction (COVID 19 PCR) test result she underwent surgery, subtotal cholecystectomy, intraoperative cholangiography, and choledochoplasty. No perioperative complications were noted. This patient was managed with the goal of providing excellent patient care while limiting risks from COVID 19 both to the patient and the health care team. This case demonstrates the need to address issues brought about by the pandemic resulting in limitations in resources, added risk of morbidity to patients, and increased level of technical difficulty particularly in biliary surgery.

1349 A Rare Presentation of Cholecystogastric Fistula With Associated Mirizzi Syndrome Leading to the Diagnosis of Gallbladder Cancer

INTRODUCTION: Biliary fistulas are a rare complication of gallstone disease. Technological advances have allowed for successful management &amp; diagnosis. Mirizzi syndrome is a condition seen in less than 1% of patients with cholelithiasis &amp; malignancy in 5 to 28% of cases. This is a rare presentation of coexistent Mirizzi syndrome and a cholecystogastric fistula leading to the diagnosis of gallbladder adenocarcinoma. CASE DESCRIPTION/METHODS: A 68 y/o female presented to the ER with complaints of jaundice &amp; pruritis. Records demonstrated prior CTA&amp;P with cholelithiasis with stranding &amp; nonspecific stranding around the distal stomach. MRI w/wo contrast demonstrated loss of fat plane between gallbladder &amp; stomach suggestive of fistulizing disease &amp; a filling defect within the extrahepatic common hepatic duct related to external compression suggestive of Mirizzi Syndrome, no pneumobilia was seen. EGD/EUS was without direct visualization a fistulous tract, but revealed ulceration of gastric mucosa suggesting extrinsic pressure from a gallstone. ERCP demonstrated a stricture within the proximal CBD. Brushings were negative for malignancy. Lap chole revealed adherence of the stomach to the gallbladder fundus &amp; takedown of cholecystogastric fistula was also performed. Histology from gallbladder specimen returned positive for invasive poorly-differentiated adenocarcinoma with transmural and lymphatic invasion. DISCUSSION: The presentation of cholecystogastric fistula generally includes pneumobilia &amp; lacks pruritis suggestive of obstructive jaundice due to drainage of the biliary system via tract formation. Yet during the development of the fistulous tract the presentation varies quite drastically. Surgery is guided by the sub-classification of fistula formation/erosion as noted in the table figure. ERCP allows better characterization of the anatomy, in addition to offering the potential for therapeutic intervention with biliary decompression. There is an important known relationship between Mirizzi syndrome &amp; gallbladder cancer likely related to the recurrent irritation occurring in the region along with chronic biliary stasis therefore frozen sections should be performed in all cases of Mirizzi syndrome to conclusively evaluate for gallbladder cancer. Our case highlights the malignancy potential within the presentation of fistulizing gallbladder disease. With a heightened index of suspicion and advancements in endoscopic and surgical techniques management of these patients will hopefully become less challenging.

Cholecystitis with Spontaneous Cholecysto-Cutaneous Fistula

Background An external biliary fistula is a rare complication of gallstone disease. We present a case of cholecystocutaneous fistula successfully treated with excision and cholecystectomy. Case outline An 87-year old woman presented to the emergency department with an abdominal inflammatory mass in the right flank increasing for 15 days. Results Physical examination revealed signs of decompensated heart failure associated with hypothermia. Abdominal ultrasound showed a fluid collection in the right abdominal wall evaluated to 15x13x6 cm containing air bubbles and a stone. Discussion This condition is never seen today because of the bigger availableness of computerized axial tomography confirmed associate symptom within the paries containing a three cm stone ad lib exhausted from the vesica. The symptom and therefore the stone were exhausted with a body covering incision concerning the symptom below anesthesia.

Bouveret's syndrome: A rare presentation of gallstone disease

fistula is a rare complication of gallstone disease and gallstone ileus is relatively a rare cause of intestinal obstruction. In most cases, the stone lodges in the distal ileum, colon or duodenum. The least common site of obstruction is the proximal duodenum or pylorus causing gastric outlet obstruction (Bouveret's syndrome). Presenting signs and symptoms of Bouveret's syndrome include nausea, vomiting, epigastric pain, and abdominal distension. Obstructive jaundice, gastrointestinal hemorrhage with or without hematemesis, pancreatitis, and duodenal perforation are less common. Abdominal radiography may show air in the biliary tree, mechanical bowel obstruction and radio-opaque gallstone suggesting the diagnosis. Abdominal ultrasound or computerized tomography is diagnostic in about 60% of cases. In most cases the treatment of Bouveret's syndrome is surgical. Surgical options include: (a) a single-staged enterolithotomy (or gastrotomy) with concomitant cholecystectomy and repair of the fistula or (b) an enterolithotomy alone with or without a second-stage cholecystectomy. Endoscopic extraction of the stone has been described in selected patients. Lithotripsy techniques have also been successfully used to fragment large stones. The authors present a case of Bouveret's syndrome as well as a brief literature review of this topic. DISCUSSIONfistula is a rare complication of gallstone disease (incidence, 0.3-0.5%) and gallstone ileus is relatively a rare cause of intestinal obstruction (3%). Most commonly the stone lodges in the distal ileum (90%), colon (3%-8%) or duodenum (3%). The least common site of obstruction is the proximal duodenum or pylorus causing gastric outlet obstruction, which is known as Bouveret's syndrome. The condition's presenting clinical signs and symptoms usually include nausea, vomiting, epigastric pain, and abdominal distension. Obstructive jaundice, gastrointestinal hemorrhage with or without hematemesis, pancreatitis, and

An Unusual Complication of Gallstones: Mirizzi Syndrome - A Case Report and Literature Review

1 Department of Medicine, Capital Development Authority (CDA) Hospital, Islamabad, Pakistan 2 Department of Medicine, Capital Development Authority (CDA) Hospital, Islamabad, Pakistan 3 Department of Medicine, Capital Development Authority (CDA) Hospital, Islamabad, Pakistan Corresponding Author Adnan Bashir Bhatti, MD Email: dr.adnanbashir@gmail.com Abstract Mirizzi syndrome is a rare complication of gallstone disease, causing major biliary problems, if the diagnosis is not made early. This condition was also reported to occur in the setting of acute acalculous cholecystitis. It was first described in 1948 by Pablo Mirizzi and presented itself in the form of unusually lodged gallstone in either the cystic duct or most frequently in Hartmann pouch of the gallbladder. We report a 50-year-old female with exquisite pain in right hypochondrium and epigastrium with nausea and vomiting for the last 20 days. She also had yellowish discoloration of urine, clay-colored stools, and tender right hypochondrium. Laboratory investigations revealed raised liver enzymes and ultrasonography (USG) was inconclusive in describing an impacted stone in the gallbladder neck. Computerized tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) revealed it as suspected case of a mirizzi syndrome which was later confirmed by surgery. The patient was recovered after surgery without complications.