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CASEREPORT

Spontaneous Relief of Mechanical Bowel Obstruction in Gallstone Ileus

Abdallah Glessa, Salah Mansor, Khaled Elgazwi

DepartmentofGeneralSurgery,AljalaUniversityHospital,GarYounisUniversity,Benghazi,Libya

AbstractWe report the case of a 60-year-old female Libyanpatient who presented with a three day history ofvomiting, colicky abdominal pain, and constipation.Shewasdehydrated, tachycardiac,with adistended,tenderabdomenandexaggeratedbowel sounds.Shehadleucocytosisandanincreasedbloodureanitrogenlevel. Plain abdominal x-ray films showed dilatedsmall bowel loops andpneumobilia.Ultrasoundandcomputed tomography (CT) examinations confirmedthediagnosisofgallstoneileus.Theobstructionwasspontaneously relievedbypassing the stone into thececum.

Key words: Gallstone ileus, intestinal obstruction,pneumonia

IntroductionGallstone ileus refers to a mechanical intestinalobstruction that is rarely causedbygallstones. It isanuncommonandpotentiallyseriouscomplicationofcholelithiasis (1,2). In themajority (75%)of cases,thediseasedgallbladderopensintotheduodenumbyafistula,andthestoneenterstheintestinaltractwhereit becomes impacted in the bowel lumen near theileocecalvalve.

Itwas first described byBartholin in 1654 (3).Theformationofafistulabetweenthegallbladderandtheduodenummayallowagallstonetoentertheintestinaltract.Cholecystoduodenalfistulaisthemostfrequent(75%),followedbycholecystocolicfistula(10-20%),and a variety of other types (15%). Spontaneousenterobiliary fistula occur secondary to biliarydisease,anddiseaseofadjacentstructures.Theseare

Correspondingauthor:Dr.SalahMansorEmail:Salah72LY@Yahoo.comPublished:26November2011IbnosinaJMedBS2011,3(6):218-222Received:30December2010Accepted:10August2011Thisarticleisavailablefrom:http://www.ijmbs.orgThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution3.0Licensewhichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

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usuallyassociatedwithgallstonesbuthavealsobeenreportedwithpepticulcerdisease,abdominaltrauma,Crohn’sdisease,andmalignanciesofthebiliarytract,bowel,andheadofthepancreas(4).Theobstructionusuallyoccursattheleveloftheileocecalvalve(5).The mortality and morbidity of gallstone ileus arehigh because it is common in older aged patients,when the presence of concomitant diseases is oftennoted, and it is frequently a late diagnosis (6). Thedelay indiagnosis isdue to thenon-specificclinicalpresentation of the condition (7,8).The diagnosis is

confirmedbyplainx-rayfilms,abdominalultrasound,andCTexaminations.Presence of pneumobilia, ectopic gallstone, andmechanicalobstruction (Rigler’s triad)demonstratedinplainfilmsareonlyseeninabout50%ofcases(9)and there are recent reports advocating early use ofother imaging modalities like abdominal ultrasound(US) and computed tomography (CT) scans forearlydiagnosis(2,7,10,11).Gallstoneileus is treatedsurgically by enterolithotomy with or withoutcholecystectomyandclosureofthefistula.Wepresent

Figure1:Aplainabdominalfilmshowedadilatedsmallintestineintheupperabdomenwithairshadowatareaofgallbladder(Ar-row),laterwithcomparingwithCTfindingitwasfreeairinsidegallbladder.

Figure 2: Coronal view of abdominal computed tomography(CT)imageshowinganabnormalGasinthegallbladder(Closearrow)andincommonbileduct(Openarrow).Pneumobilia.

Figure 3:Axialviewofabdominalcomputedtomography(CT),imageshowinganabnormalGasintheintrahepaticbiliaryducts.

Figure 4: Coronal view of abdominal computed tomography,imageshowingashadowofmultipleectopicsmallstoneslo-catedinthececum(Arrow).

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here an illustrative case with spontaneous relief ofgallstoneileusbypassingthestoneintothececum.

Case ReportA 60-year old woman presented to our emergencydepartment with a case of intestinal obstructionof three days history. Symptoms were vomiting,distension, constipation and abdominal pain. Onphysical examination, her abdomen was tenderwithmild abdominal distension.Murphy’s signwasnegative.Thewhitebloodcountwas16.3/dl,bloodureanitrogen64mg/dL,theothertestswere unremarkable.A plain abdominal film showedadilatedsmall intestinal loop in theupperabdomenwithairshadowattheareaofthegallbladder(Figure1). On the second day of admission, the patientclinicallyimproved.Allsymptomshadimprovedandherobstructionwasrelieved.Abdominalsonographicexaminationwasperformedonedayafteradmissionand the findings included contracted gallbladderwith thickened wall, without stones, presence ofair in the intrahepatic biliary tree, and dilated smallbowel with increased peristalsis suggestive ofintestinal obstruction. For a detailed analysis ofintraluminal air shadowing, the patientwas referredfor non-contrast abdominal computed tomography(CT).TheCT images showed abnormal gas in thegallbladder, in the common bile duct (Figure 2),and in the intrahepaticbiliaryducts (Figure3). Thepresence of these abnormal gas shadows and thedilatedsmallintestinewithshadowofmultiplesmallstones located in the cecum (Figure 4), confirmedthe presence of gallstone ileus.Magnetic resonancecholangiopancreatography(MRCP) revealedaclearfistula tract connecting the gallbladder andfirst partofduodenum(Figure5).Thepatienthadbeentreatedafteradmissionwithintravenousfluids(0.9%sodiumchloride) and nasogastric decompression, Rocephin1gm intravenously (IV)oncedaily, andOmeprazole40mgIVoncedaily.Theinputandoutputofallfluidswere recorded. The patient’s condition improveddramatically and she underwent surgery one weekafterheradmission.Througharightupperparamedianincision, a small contracted gallbladder with denseadhesionstotheomentumandduodenumwasfound.

Afterdividingbtheadhesions,afistuloustractbetweenthegallbladderandfirstpartofduodenumwasfound(Figure 6).The tractwas divided.Cholecystectomyandrepairoftheholeintheduodenumintwolayersusingpolyglycolicacid2/0sutureswereperformed.Thepostoperativecoursewasuneventful.

DiscussionClinical diagnosis of gallstone ileus is difficult andusually depends on the radiographic findings. Thepresenceof twosignsof theclassicRigler’s triad isconsidered pathognomonic in 50% of patients. In50%ofthesecases,thediagnosisisoftenmadeonlyatlaparotomy(6).However,airinthegallbladderisalsoafrequentfindingingallstoneileus(14).Plainabdominal films usually show non-specific findingsbecause only 10% of gallstones are sufficientlycalcified enough to be visualized radiographically.Abdominal sonography is useful to confirm thepresenceofcholelithiasis,andmayidentifyafistula(15).Inourpatient,sonographicfindingsdemonstrateda thickened gallbladder wall without stones, anddilated small intestine. Abdominal CT, because ofits better resolution, is amore important diagnosticmodalityingallstoneileus.BycomparingtheCTscanwiththeplainabdomenfilmandabdominalsonogram,amorerapidandspecificdiagnosiscanbereached.IthasbeensuggestedthatabdominalCTofferscrucialevidencenotonlyforthediagnosisofgallstoneileusbut also for the decision regarding managementstrategy (10,7). Gallstone ileus usually requiresemergency surgery to relieve intestinal obstruction.There is no uniform surgical procedure for thisdiseasebecauseofitslowincidence.Bowelresectionisonlyindicatedwhenthereis intestinalperforationor ischemia (16)/ Although enterolithotomy aloneremainsthepopularoperativemethodinmostreports,theone-stageprocedurecomposedofenterolithotomy,cholecystectomy and repair of fistula may benecessary(17).Enterolithotomyaloneisthepreferredoperationmore thanenterolithotomycombinedwithcholecystectomy(18),thoughbothproceduresaresafewithlittleriskofmortality.Theone-stageprocedureshould be reserved only for highly selected patientwithabsoluteindications(19).Inourpatient,because

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her obstruction state was relieved spontaneously,therewasnoindicationforurgentsurgicaltreatment,andwepreparedthepatientforelectivesurgery.Theoperationwascompletedduring thesameadmissionwithcholecystectomyandfistularepair.

Recently, laparoscopy-guided enterolithotomy hasbecome the preferred surgical approach in treatinggallstone ileus (20). Additionally, the non-surgicaltreatment of gallstone ileus has been suggested,including endoscopic removal and shockwavelithotripsy, but this depends on the location ofobstruction(21,22).Theprognosisofgallstoneileusisusuallypoorandworsenswithage.Themortalityrate ranges between 7.5%-15% (6,13), largely dueto delayed diagnosis and concomitant conditionssuch as cardio-respiratory disease, obesity, anddiabetes mellitus. The postoperative recurrence rateofgallstone ileus is4.7%,andonly10%ofpatientsrequiresecondarybiliarysurgeryforrecurrentbiliarysymptoms(6,23).

We conclude that in gallstone ileus, if the clinicalsigns and symptoms, or imaging evidence, arenot consistent with those of complete intestinalobstruction, spontaneous resolution is possible andshouldbeinitiallycautiouslyexpected.

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