Gallstone ileus: the importance of individualized management

Gallstone ileus represents a complication of cholelithiasis, which in the literature has been reported as a rare cause of mechanical intestinal obstruction, however, the reported incidence is not so low, especially after 65 years of age. The formation of a bilioenteric fistula allows the passage of a large gallstone into the intestine, usually impacting the distal intestine. It is associated with a mortality that ranges between 12 and 27%. Treatment is surgical, although there is no consensus on which of the surgical techniques is the one of choice. We report the case of an 87-year-old male patient who was admitted to the emergency department with intestinal obstruction. He was diagnosed with gallstone ileus and was treated surgically with exploratory laparotomy, enterotomy with stone extraction, and primary closure. The evolution was favorable and without complications.

Gallstones Ileus

The ileus of gallstones is a rare complication of cholelithiasis which occurs in less than 1% of patients and is the cause of 1–4% of cases of obstruction of the small intestine. The pathogenesis involves the formation of a bilioenteric fistula. Abdominal computed tomography (CT) shows pneumobilia, dilated loops of small intestine, and ectopic gallstones that obstruct the intestinal lumen. In literature, enterolithotomy is the most frequently used procedure for the ileum of gallstones. Enterolithotomy plus cholecystectomy and/or fistulectomy are indicated only in selected patients. The clinical signs and symptoms depend on the site of the obstruction and usually include abdominal pain, nausea, and vomiting. The diagnostic test of choice is an abdominal CT scan.

Gallbladder-duodenal fistula detected by ultrasound – a case report

Gallbladder-duodenal (cholecystoduodenal) fistula is an uncommon bilioenteric fistula between the gallbladder and the duodenum. It usually occurs following a chronic case of cholecystitis upon which the gallbladder adheres to the adjacent duodenum, and a stone penetrates through the wall. The case presented herein is that of a gallbladder-duodenal fistula detected primarily with the use of ultrasound imaging, and subsequently confirmed by computed tomography. The patient is a 54-year-old woman who was admitted with upper abdominal pain. The fistula was caused by chronic cholecystitis, however no gallstones were present in the duodenum. Surgical management was undertaken for the patient, and the recovery was uneventful.

Bouveret’s syndrome: A challenging case of gastric outlet obstruction.

Bouveret’s syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. We present case of a 40-year-old female presented with epigastric pain and intractable vomiting for 2 days. Her physical examination and laboratory workup including blood analysis, amylase test and lipase test were normal. Plain abdominal X-ray did not show any signs of small bowel obstruction. A nasogastric tube was placed and drained 2.5 L of gastric contents immediately. Esophagogastroduodenoscopy showed a dilated stomach with excessive secretions and a large blackish-brown hard stone in the duodenal bulb. After failed attempt at endoscopic extraction, patient underwent laparotomy and removal of stone via duodenal incision. Subsequently, the patient exhibited a good postoperative recovery. The condition of the patient has remained stable after being followed up for one year.

The curious case of biliary emesis and bowel obstruction from Bouveret syndrome

Bouveret syndrome is a rare complication of biliary lithiasis. This sequela is caused by the passage of the gallstone via a bilioenteric fistula, resulting in an impacted gallstone in the duodenum or stomach. The common presentation of non-specific symptoms contributes to the diagnostic uncertainty and delay, which is strongly associated with adverse outcomes. We report an uncomplicated stone extraction via open gastrotomy in an elderly man afflicted with bowel obstruction and biliary vomit secondary to Bouveret syndrome.

Bouveret’s syndrome treated with endoscopic electrohydraulic lithotripsy

Bouveret’s syndrome is a rare form of small bowel obstruction caused by a large biliary stone entering the lumen of the duodenum or the stomach through a bilioenteric fistula. Treatment options include various surgical techniques. However, recent advances in endoscopy also allow non-surgical endoscopic treatment options. We report a 68-year-old man, with a disseminated small intestinal neuroendocrine tumour, presenting with Bouveret’s syndrome without any previously reported biliary disease. He experienced a number of symptoms 1 month prior to his admittance, which were difficult to differentiate from other infectious diseases and complications due to his neuroendocrine tumour. Abdominal CT showed a biliary stone impacted in the duodenal bulb, small bowel obstruction, pneumobilia and a bilioenteric fistula. The patient was treated with endoscopic electrohydraulic lithotripsy to fragment the large gallstone in smaller retractable pieces. The patient avoided major surgery and was discharged the following day.

Biliocolonic Fistula Through Cystic Duct Remnant

Cystic duct remnant-colonic fistula is a rare entity. Only a few cases have been reported in the literature. They usually arise after open or laparoscopic cholecystectomy for gallstone diseases. Other causes may include malignancies and inflammatory bowel diseases. We are presenting a case of bilioenteric fistula involving cystic duct remnant and transverse colon in a female patient who had undergone open cholecystectomy five years before. JMS 2018: 21 (2):120-121